*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 __________________________ FEIN#: _____________________________________________________ Business Address (Street,City,State,Zip) __________________________ Date Signed Subscribed and sworn to me this ________ day of ______ , 20______ _____________________________________________________ Signature of Notary Public __________________________ Date Commission Expires LEASED OPERATOR AND/OR LEASED OWNER/OPERATOR’S AFFIRMATION _____________________________________ ( )Leased Operator Printed & Sign Name ( )Leased Owner/Operator _______________________ Social Security Number __________________________________________________________ Business Address (Street, City, State, Zip) ________________________ Date Signed Subscribed and sworn to me this _________ day of ______ , 20______ _______________________________________________________ Signature of Notary Public LB-0300 (REV. 12/07) __________________________ Date Commission Expires RDA 10183 American LegalNet, Inc. www.FormsWorkflow.com