Notice Of Waiver By Employee For Benefits In Claims Growing Out Of Aggravation Or Repetition Of Heart Disease
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Notice Of Waiver By Employee For Benefits In Claims Growing Out Of Aggravation Or Repetition Of Heart Disease 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 In Claims Growing Out Of Aggravation Or Repetition Of Heart Disease, I-10, Tennessee Workers Compensation,
*The Form Must Be Original & Completed In Pen*
FORM I-10
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 IN CLAIMS GROWING OUT OF AGGRAVATION OR
REPETITION OF HEART DISEASE, HEART ATTACK OR CORONARY FAILURE OR
OCCLUSION
As provided in Section 50-6-307 of the Tennessee Code Annotated, notice is hereby given that
_____________________________________________________________________________
(Employee or prospective employee)
of ___________________________________________________________________________
Business Name
FEIN #:
_____________________________________________________________________________
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 aggravation or repetition of heart disease, heart attack or coronary
failure or occlusion. The undersigned does hereby specifically waive any and all claims for benefits either for
himself or for anyone else claiming by or through or on account of him which may arise in the future on
account of the aforesaid heart condition. Copy of medical statement with the Doctor's signature in pen, giving
the prior history for the heart condition, is attached hereto.
_____________________________________________________
Employee’s Signature
_______________________________________________________________
Social Security Number
_______________________________________________________________
Date Signed
LB-0030 (REV. 12/07)
RDA 10183
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