Free APPENDIX A - Tennessee

*The Form Must Be Original & Completed In Pen*
FORM I-11 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002 NOTICE OF WAIVER BY EMPLOYEE FOR BENEFITS PROVIDED BY THE TENNESSEE WORKERS' COMPENSATION LAW IN CLAIMS ARISING OUT OF OCCUPATIONAL DISEASES

I,______________________________________________________, an Employee
(Employee or prospective employee)

Of ______________________________________________________________________________
Business Name FEIN # ____________________________________________________________________________________________ Business Address ____________________________________________________________________________________________ Business Address

hereby give written notice to the Tennessee Workers' Compensation Division that I have received medical advice that I am affected by or susceptible to

______________________________________________________________________________
Name of Disease

an occupational disease as defined in Section 50-6-301 of the Tennessee Code Annotated and wish to waive any and all claims for benefits either for myself or for anyone else claiming by or through or on account of me which may arise in the future on account of the aforesaid disease. Copy of medical statement with Doctor's signature in pen, verifying that I am affected by or susceptible to the named disease, is attached.
_______________________________________________________________ Employee's signature _______________________________________________________________ Social Security Number ________________________________________________________________ Business Address ________________________________________________________________ Business Address

Dated this _____________day of________________________, 20______.
LB-0279 (REV. 12/07) RDA 10183