LB-0228 (REV 6/17) RDA 10183 Tennessee Bureau of Workers325 Compensation 220 French Landing Drive, I-B Nashville, TN 37243-1002 800-332-2667 FORM I-4 NOTICE OF ELECTION This form is to be completed by a: 245 sole proprietor, 245 member of an LLC, or 245 partner who is not a construction services provider as defined in T.C.A 24450-6-901, who wishes to be considered as an employee and elects to come under the provisions of the Tennessee Workers325 Compensation Law. This form is not to be filed with the Bureau of Workers325 Compensation. To , the Insurance Carrier of the Business named below: You are hereby notified that I, Type or Print Individual325s Name being a (check one) ( ) Sole Proprietor ( ) Member of LLC ( ) Partner in the following business: Business Name & FEIN: hereby elects to come under the provisions of the Tennessee Workers' Compensation Law. Signature Social Security Number Business Physical Street Address City State Zip Business Mailing Address City State Zip Signed this day of , 20. American LegalNet, Inc. www.FormsWorkFlow.com