Free APPENDIX A - Tennessee

*The Form Must Be Original & Completed In Pen*
FORM I-10

TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation 220 French Landing Drive Nashville, Tennessee 37243-1002

NOTICE OF WAIVER BY EMPLOYEE FOR BENEFITS PROVIDED BY THE TENNESSEE WORKERS' COMPENSATION LAW IN CLAIMS GROWING OUT OF AGGRAVATION OR REPETITION OF HEART DISEASE, HEART ATTACK OR CORONARY FAILURE OR OCCLUSION As provided in Section 50-6-307 of the Tennessee Code Annotated, notice is hereby given that _____________________________________________________________________________
(Employee or prospective employee)

of ___________________________________________________________________________
Business Name FEIN #:

_____________________________________________________________________________
Business Address

_____________________________________________________________________________
Business Address

hereby gives written notice to the Division of Workers' Compensation, Tennessee Department of Labor, of his waiver of compensation benefits for any aggravation or repetition of heart disease, heart attack or coronary failure or occlusion. The undersigned does hereby specifically waive any and all claims for benefits either for himself or for anyone else claiming by or through or on account of him which may arise in the future on account of the aforesaid heart condition. Copy of medical statement with the Doctor's signature in pen, giving the prior history for the heart condition, is attached hereto. _____________________________________________________
Employee's Signature _______________________________________________________________ Social Security Number _______________________________________________________________ Date Signed

LB-0030 (REV. 12/07)

RDA 10183