Notice Of Corporate Officer To Employer Of Election Not To Accept Provisions Of Workers Compensation Act Of Tennessee Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Notice Of Corporate Officer To Employer Of Election Not To Accept Provisions Of Workers Compensation Act Of Tennessee Form. This is a Tennessee form and can be use in Workers Compensation.
Loading PDF...
Tags: Notice Of Corporate Officer To Employer Of Election Not To Accept Provisions Of Workers Compensation Act Of Tennessee, I-6, Tennessee Workers Compensation,
*The Form Must Be Original & Completed In Pen*
FORM I-6
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation
220 French Landing Drive
Nashville, Tennessee 37243-1002
NOTICE OF CORPORATE OFFICER TO EMPLOYER OF ELECTION NOT TO ACCEPT PROVISIONS OF
“WORKERS’ COMPENSATION ACT” OF TENNESSEE.
INSTRUCTIONS:
File an original, a photocopy of the completed original and a self-addressed stamped envelope (approved copy will be
returned). The form must be complete, legible and notarized. If any information is missing, the form will be returned
and will prolong the effective date until form is received complete. The effective date is 30 days after approved stamped
date. Once approved the form is effective until withdrawn by the filing of a “FORM I-7 Notice of Corporate Officer’s
Revocation of Exemption” form. If the Business Name or corporate officers names or titles change a new form must be
filed.
Business Name ___________________________________________
FEIN #_________________
Business Address
City
State
Zip
Please furnish name and address of company or individual submitting this form.
Name _________________________________Address _______________________________________________
You are hereby notified that the undersigned corporate officer elects not to be bound by the provisions of the Tennessee
Workers’ Compensation Act in compliance with section 50-6-104 of the said “Workers’ Compensation Act”
CORPORATE OFFICER REJECTING COVERAGE
(PRINT)
NAME___________________________________________________ CHECK TITLE:
President
Secretary
CEO
COO
V.P.
Treasurer
CFO
SIGNATURE_________________________________________SSN#:_______________________
Signed this ______________________day of ____________________________, 20_____________
Subscribed and sworn to before me this __________day of _____________,20________
Notary Public____________________________________________________________
My commission expires_______________________________________, 20__________
This is to certify that the above named corporate officer has served notice on his/her employer and said employer has not
advised, counseled or encouraged the corporate officer to reject the provisions of the Workers Compensation Act , in
compliance of section 50-6-104(b).
Employer Signature_______________________________________________________________
(“Only” the “President” can sign as his/her own employer)
LB-0090 (REV. 12/07)
RDA 10183
American LegalNet, Inc.
www.FormsWorkflow.com