Notice Of Waiver By Employee For Benefits In Claims Arising Out Of Occupational Diseases
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Notice Of Waiver By Employee For Benefits In Claims Arising Out Of Occupational Diseases Form. This is a Tennessee form and can be use in Workers Compensation.
Tags: Notice Of Waiver By Employee For Benefits In Claims Arising Out Of Occupational Diseases, I-11, Tennessee Workers Compensation,
*The Form Must Be Original & Completed In Pen*
FORM I-11
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation
220 French Landing Dr.
Nashville, Tennessee 37243-1002
NOTICE OF WAIVER BY EMPLOYEE FOR BENEFITS PROVIDED BY THE TENNESSEE
WORKERS' COMPENSATION LAW IN CLAIMS ARISING OUT OF
OCCUPATIONAL DISEASES
I,______________________________________________________, an Employee
(Employee or prospective employee)
Of
______________________________________________________________________________
Business Name
FEIN #
____________________________________________________________________________________________
Business Address
____________________________________________________________________________________________
Business Address
hereby give written notice to the Tennessee Workers' Compensation Division that I have received medical
advice that I am affected by or susceptible to
______________________________________________________________________________
Name of Disease
an occupational disease as defined in Section 50-6-301 of the Tennessee Code Annotated and wish to waive
any and all claims for benefits either for myself or for anyone else claiming by or through or on account of me
which may arise in the future on account of the aforesaid disease. Copy of medical statement with Doctor's
signature in pen, verifying that I am affected by or susceptible to the named disease, is attached.
_______________________________________________________________
Employee’s signature
_______________________________________________________________
Social Security Number
________________________________________________________________
Business Address
________________________________________________________________
Business Address
Dated this _____________day of________________________, 20______.
LB-0279 (REV. 12/07)
RDA 10183
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