Free APPENDIX A - Tennessee

*The Form Must Be Original & Completed In Pen*
FORM I-16 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002

NOTICE OF TERMINATION OF AGREEMENT OF COMMON CARRIER WITH LEASED OPERATOR AND/OR LEASED OWNER/OPERATOR

I hereby notify the Tennessee Workers' Compensation Division that I, ____________________________________________________________being a
Common Carriers Business Name or Leased Operator/Owner Operators Name & FEIN #

common carrier

leased operator or leased owner/operator

wish to withdraw my agreement of workers' compensation insurance coverage with: common carrier ________________________________________________________ Business Name leased operator or leased owner/operator ____________________________________________________________________ Individual Name _______________________________________
Signature of Leased Op/Owner Operator _____________________________________________ Signature of Common Carrier

_______________________________________
Social Security Number

_______________________________________
Business Address

_______________________________________
Business Address

Signed this _______________day of_______________, 20_______.

LB-0353 (REV. 12/07)

RDA 10183