LB-0014 (REV. 5/18) RDA 10183 Tennessee Bureau of Workers222 Compensation 220 French Landing Drive, I-B Nashville, TN 37243-1002 800-332-2667 FORM I-8 NOTICE OF ACCEPTANCE OF THE "TENNESSEE WORKERS' COMPENSATION ACT" BY AN EXEMPTED EMPLOYER Notice is hereby given that Employer name FEIN located at (Full physical street address) located at (Full mailing address, if different from above) elects to operate under the provisions of Title 50 Chapter 6, officially designated as the "Tennessee Workers' Compensation Act224, the said employer being otherwise exempt from the provisions of the Act, as provided by Section 50-6-106 of the Tennessee Code Annotated, due to: 1. It only employs Domestic Servants as defined by the Act 2. It is a Department or Division of the State, Counties, or Municipal Corporation (If so, please submit one I-8 form for each Department or Division accepting the provisions of the Act.) 3. Other In compliance with Section 50-6-405 of the Tennessee Code Annotated, the undersigned employer has insured his liability hereunder in the following manner-to-wit: (Workers222 Compensation Insurance Coverage Providers Name or indication of being a qualified Self-Insurer) (Full mailing address) Section 50-6-405 of the Tennessee Code Annotated reads, in part: Every employer under and affected by the workers' compensation law (1) shall insure and keep insured his liability hereunder in some person or persons, association, organization or corporation authorized to transact the business of workers' compensation insurance in this state; or (2) shall furnish to the commissioner of commerce and insurance satisfactory proof of his financial ability to pay all claims that may arise against such employer under this chapter and guarantee the payment of the same in the amount and manner and when due as provided for in this chapter. If the employer elects to pursue the latter course, the commissioner of commerce and insurance shall, without discretion, require the deposit of an acceptable security of indemnity bond to secure the payment of compensation liability as may be insured under such law. Said bond shall be conditioned to run directly for the benefit of the employees subject to the workers' compensation law, and may be enforced by them directly in an action in their name. This chapter shall not apply to policies of insurance against loss from explosion of boiler or fly wheels, or other similar single catastrophe hazards. (Printed name, title and phone #) (Signature and date) American LegalNet, Inc. www.FormsWorkFlow.com