Notice Of Termination Of Agreement Of General Contractor With Subcontractor
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Notice Of Termination Of Agreement Of General Contractor With Subcontractor Form. This is a Tennessee form and can be use in Workers Compensation.
Loading PDF...
Tags: Notice Of Termination Of Agreement Of General Contractor With Subcontractor, I-17, Tennessee Workers Compensation,
*The Form Must Be Original & Completed In Pen*
FORM I-17
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation
220 French Landing Drive
Nashville, Tennessee 37243-1002
NOTICE OF TERMINATION OF AGREEMENT OF GENERAL
CONTRACTOR WITH SUBCONTRACTOR
I hereby notify the Tennessee Workers' Compensation Division that
I,
(General Contractors Business Name and/or Sub-contractors Name
General contractor
_______________ being a
&
FEIN #)
Subcontractor wish to withdraw my agreement of workers' compensation
insurance coverage with:
General contractor _____________________________________________________
Generals Business Name
Subcontractor ________________________________________________________
Sub-contractors Individual Name
___________________________________________________
Signature of Sub-Contractor or General
____________________________________________________________
Social Security Number
____________________________________________________________
Business Address
____________________________________________________________
Business Address
Signed this _______________day of_______________, 20_______.
LB-0354 (REV. 12/07)
RDA 10183
American LegalNet, Inc.
www.FormsWorkflow.com
