*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 _____________________________ 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 SUBCONTRACTOR’S AFFIRMATION ___________________________________________________ Print & Sign Name of Subcontractor _____________________________ 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-0301 (REV. 12/07) __________________________ Date Commission Expires RDA 10183 American LegalNet, Inc. www.FormsWorkflow.com