Notice Of Termination Of Agreement Of Common Carrier With Leased Operator And Or Leased Owner-Operator
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Notice Of Termination Of Agreement Of Common Carrier With Leased Operator And Or Leased Owner-Operator Form. This is a Tennessee form and can be use in Workers Compensation.
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Tags: Notice Of Termination Of Agreement Of Common Carrier With Leased Operator And Or Leased Owner-Operator, I-16, Tennessee Workers Compensation,
*The Form Must Be Original & Completed In Pen*
FORM I-16
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation
220 French Landing Dr.
Nashville, Tennessee 37243-1002
NOTICE OF TERMINATION OF AGREEMENT OF COMMON CARRIER
WITH LEASED OPERATOR AND/OR LEASED OWNER/OPERATOR
I hereby notify the Tennessee Workers' Compensation Division that
I, ____________________________________________________________being a
Common Carriers Business Name or Leased Operator/Owner Operators Name & FEIN #
common carrier
leased operator or leased owner/operator
wish to withdraw my agreement of workers' compensation insurance coverage with:
common carrier ________________________________________________________
Business Name
leased operator or leased owner/operator
____________________________________________________________________
Individual Name
_______________________________________
Signature of Leased Op/Owner Operator
_____________________________________________
Signature of Common Carrier
_______________________________________
Social Security Number
_______________________________________
Business Address
_______________________________________
Business Address
Signed this _______________day of_______________, 20_______.
LB-0353 (REV. 12/07)
RDA 10183
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