Election Of Sole Proprietor Or Partner To Come Within The Provisions Of The Tennessee Workers Compensation Law
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Election Of Sole Proprietor Or Partner To Come Within The Provisions Of The Tennessee Workers Compensation Law Form. This is a Tennessee form and can be use in Workers Compensation.
Loading PDF...
Tags: Election Of Sole Proprietor Or Partner To Come Within The Provisions Of The Tennessee Workers Compensation Law, I-4, Tennessee Workers Compensation,
*The Form Must Be Original & Completed In Pen*
FORM I-4
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation
220 French Landing Drive
Nashville, Tennessee 37243-1002
ELECTION OF SOLE PROPRIETOR OR PARTNER TO COME WITHIN THE PROVISIONS OF
THE TENNESSEE WORKERS' COMPENSATION LAW
FORM EFFECTIVE 30 DAYS AFTER TENNESSEE DEPARTMENT OF LABOR'S ACCEPTED STAMP DATE.
ORIGINAL TO BE SENT TO THE DIVISION OF WORKERS' COMPENSATION WITH ALL PARTS FILLED OUT AND
PROPERLY SWORN TO BEFORE NOTARY PUBLIC OR OTHER OFFICIAL.
To the Workers' Compensation Director:
You are hereby notified that the undersigned
Type or Print Name
being a
( ) Sole proprietor
( ) Member
( ) Partner
and being engaged as such in the occupation or business of:
Business name & Federal Employer Identification Number:
in the State of Tennessee, hereby elects to come under the provisions of the Tennessee Workers' Compensation
Law.
____________________________________________
Signature
____________________________________________
Social Security Number
____________________________________________
Business Address: Street, City, State & Zip
Signed this ________day of ____________________, 20______.
Before me, the undersigned, a notary public in and for the county of __________________________________________
comes ___________________________, who is personally known to me to be the same person who executed the
foregoing instrument of writing and such persons duly acknowledged the same to be his voluntary act and deed for the
purposes of said writing herein set out.
WITNESS my hand and my notary seal, this ______day of__________________, 20______.
________________________________
Notary Public Signature
My Commission expires _____________________________________
LB-0228 (REV. 12/07)
RDA 10183
American LegalNet, Inc.
www.FormsWorkflow.com
