LB-0287 (REV 6/17) RDA 10183 Tennessee Bureau of Workers325 Compensation 220 French Landing Drive, I-B Nashville, TN 37243-1002 800-332-2667 FORM I-5 NOTICE OF WITHDRAWAL This form can be filed only by a Sole Proprietor, Member of an LLC or Partner who elects to revoke a previously-filed FORM I-4. This form is not to be filed with the Bureau of Workers325 Compensation To , the Insurance Carrier of the Business named below: You are hereby notified that I, Type or Print Name of Individual being a (check one) ( ) Sole Proprietor ( ) Member of LLC ( ) Partner in the following business: Business Name & FEIN: wish to withdraw my previously filed Form I-4. I no longer elect to come under the provisions of the Tennessee Workers' Compensation Law. Signature Social Security Number Business Physical Street Address City State Zip Business Mailing Address City State Zip Signed this day of , 20. American LegalNet, Inc. www.FormsWorkFlow.com