Notice Of Waiver By Employee For Benefits From Injuries Resulting From Epilepsy
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Notice Of Waiver By Employee For Benefits From Injuries Resulting From Epilepsy Form. This is a Tennessee form and can be use in Workers Compensation.
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Tags: Notice Of Waiver By Employee For Benefits From Injuries Resulting From Epilepsy, I-12, Tennessee Workers Compensation,
*The Form Must Be Original & Completed In Pen*
FORM I-12
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation
220 French Landing Drive
Nashville, Tennessee 37243-1002
NOTICE OF WAIVER BY EMPLOYEE FOR BENEFITS PROVIDED BY THE
TENNESSEE WORKERS' COMPENSATION LAW FROM INJURIES RESULTING FROM
EPILEPSY
As provided in Tennessee Code Annotated, Section 50-6-213, notice is hereby given that
___________________________________________________________________________
(Employee or prospective employee)
of ________________________________________________________________________
Business NameFEIN # :
___________________________________________________________________________
Business Address
___________________________________________________________________________
Business Address
hereby gives written notice to the Division of Workers' Compensation, Tennessee Department of Labor, of his
waiver of compensation benefits for any injuries sustained during the course of employment which are the
result of any epileptic seizure. This election does not effect benefits due for any other reason. This election is
not effective until a copy is filed with the Division. Copy of medical statement with Doctor's signature in
pen, giving prior history of epilepsy, is attached hereto. An election may be revoked by giving written notice
to the employer of revocation, and such revocation shall be effective upon filing a copy of such notice with
the Division of Workers' Compensation.
_____________________________________________________
Employee’s Signature
________________________________________________________________
Social Security Number
Dated this ________________day of __________________________, 20________.
LB-0046 (REV. 12/07)
RDA 10183
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