Free APPENDIX A - Tennessee

*The Form Must Be Original & Completed In Pen*
FORM I-13

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

NOTICE OF WITHDRAWAL OF WAIVER I hereby notify the Tennessee Workers' Compensation Division that I, _______________________________________________________, being an
(Employee or prospective employee)

employee of __________________________________________________________________________
Business Name FEIN #

__________________________________________________________________________
Business Address: Street City State Zip

wish to withdraw my waiver of workers' compensation benefits are:

1. Aggravation or Repetition of Heart Disease, Heart Attack or Coronary Failure or Occlusion. 2. Being affected by or susceptible to ______________________________________________
Disease

3. Injuries resulting from Epilepsy. __________________________________________________
Employee's Signature ____________________________________________________________ Social Security Number ____________________________________________________________ Business Address ____________________________________________________________ Business Address

Dated this_________________day of _______________________, 20______.
LB-0290 (REV. 12/07)
RDA 10183