Free APPENDIX A - Tennessee

*The Form Must Be Original & Completed In Pen*
FORM I-15 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Drive Nashville, Tennessee 37243-1002

AGREEMENT OF GENERAL CONTRACTOR TO PROVIDE WORKERS' COMPENSATION COVERAGE TO SUBCONTRACTOR NOTICE OF AGREEMENT
To the Workers' Compensation Director: You are hereby notified that the undersigned Subcontractor, being engaged as such by the undersigned General Contractor, hereby elects to come under the provisions of the Tennessee Workers' Compensation Law. This agreement to provide workers' compensation coverage to this Subcontractor does not provide workers' compensation coverage to this Subcontractor under any other contract to any other General Contractor.

GENERAL CONTRACTOR'S AFFIRMATION
______________________________________________________________________________________ Business Name of General Contractor __________________________________________________ Print & Sign Name of General Contractor __________________________________________________ Business Address (Street, City, State, Zip) _____________________________ FEIN# _____________________________ Date Signed

Subscribed and sworn to me this _________ day of __________, 20______ ____________________________________________________ Signature of Notary Public __________________________ Date Commission Expires

SUBCONTRACTOR'S AFFIRMATION
___________________________________________________ Print & Sign Name of Subcontractor __________________________________________________ Business Address (Street, City, State, Zip) _____________________________ Social Security Number _____________________________ Date Signed

Subscribed and sworn to me this ________ day of __________, 20______ _____________________________________________________ Signature of Notary Public __________________________ Date Commission Expires

LB-0301 (REV. 12/07)

RDA 10183