Free APPENDIX A - Tennessee

*The Form Must Be Original & Completed In Pen*
FORM I-12

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 FROM INJURIES RESULTING FROM EPILEPSY As provided in Tennessee Code Annotated, Section 50-6-213, notice is hereby given that ___________________________________________________________________________
(Employee or prospective employee)

of ________________________________________________________________________
Business NameFEIN # :

___________________________________________________________________________
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 injuries sustained during the course of employment which are the result of any epileptic seizure. This election does not effect benefits due for any other reason. This election is not effective until a copy is filed with the Division. Copy of medical statement with Doctor's signature in pen, giving prior history of epilepsy, is attached hereto. An election may be revoked by giving written notice to the employer of revocation, and such revocation shall be effective upon filing a copy of such notice with the Division of Workers' Compensation.

_____________________________________________________
Employee's Signature ________________________________________________________________ Social Security Number

Dated this ________________day of __________________________, 20________.

LB-0046 (REV. 12/07)

RDA 10183