Free TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT - Tennessee

TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Drive, 1st Floor Nashville, TN 37243-1002 FAX: 615-253-6256
REQUEST FOR INVESTIGATION (Failure to complete this form may cause a delay or result in the form being returned to requesting party) A) EMPLOYER Name of Employer: _____________________________________________________________ Employer's Federal Employment Identification Number (FEIN): __________________________ Name of Owner(s) of Employer if different from Employer: ______________________________ _____________________________________________________________________________ Name of immediate supervisor or manager, or a contact person at Employer's place of business: ____________________________________________________________________________ Street Address: _______________________________________________________________ City: ________________________ County: ______________________ State: _____________ Zip: ____________________

Business Phone: _______________________

Home Phone: _______________ Cell Phone: _____________ Fax: ___________________ How Many Employees Work for Employer (including part-time employees): ________________ Describe what kind of work the Employees of this Employer perform: _____________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ B) EMPLOYEES Names, addresses and phone numbers of Employees who work for Employer, part-time or full time (please attach additional pages if necessary to list all Employees known to requesting party). Name: _______________________________________________________________________ Address: _____________________________________________________________________ City: ___________________________ State _____________ Zip: _________________ Fax: _________________

County: ________________________ Phone: _____________ C) REQUESTING PARTY

I hereby request the Department of Labor and Workforce Development to investigate whether the Employer listed above currently has and/or has had since January 1, 2001 Workers' Compensation coverage. Printed Name of Requesting Party: __________________________________ Date: __________ Signature of Requesting Party: _____________________________________________________

LB-0977 (REV. 12/07)

RDA 10183