Free APPENDIX A - Tennessee

*The Form Must Be Original & Completed In Pen*
FORM I-14 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Drive Nashville, Tennessee 37243-1002

AGREEMENT OF COMMON CARRIER TO PROVIDE WORKERS' COMPENSATION COVERAGE TO LEASED OPERATOR AND/OR LEASED OWNER/OPERATOR NOTICE OF AGREEMENT
To the Workers' Compensation Director: You are hereby notified that the undersigned Leased Operator and/or Leased Owner/Operator, being engaged as such by the undersigned Common Carrier, hereby elects to come under the provisions of the Tennessee Workers' Compensation Law. This agreement to provide workers' compensation coverage to this Leased Operator and/or Leased Owner/Operator does not provide workers' compensation coverage to this Leased Operator and/or Leased Owner/Operator under any other contract to any other Common Carrier.

COMMON CARRIER'S AFFIRMATION
_____________________________________________________________________________________ Business Name of Common Carrier _____________________________________________________ Print & Sign Name of Common Carrier _____________________________________________________ Business Address (Street,City,State,Zip) Subscribed and sworn to me this ________ day of ______ , 20______ _____________________________________________________ Signature of Notary Public __________________________ Date Commission Expires __________________________ FEIN#: __________________________ Date Signed

LEASED OPERATOR AND/OR LEASED OWNER/OPERATOR'S AFFIRMATION
_____________________________________ ( )Leased Operator Printed & Sign Name ( )Leased Owner/Operator __________________________________________________________ Business Address (Street, City, State, Zip) Subscribed and sworn to me this _________ day of ______ , 20______ _______________________________________________________ Signature of Notary Public __________________________ Date Commission Expires _______________________ Social Security Number ________________________ Date Signed

LB-0300 (REV. 12/07)

RDA 10183