Notice Of Withdrawal From Coverage Of The Tennessee Workers Compensation Law
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Notice Of Withdrawal From Coverage Of The Tennessee Workers Compensation Law Form. This is a Tennessee form and can be use in Workers Compensation.
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Tags: Notice Of Withdrawal From Coverage Of The Tennessee Workers Compensation Law, I-3, Tennessee Workers Compensation,
*The Form Must Be Original & Completed In Pen*
FORM I-3
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation
220 French Landing Drive
Nashville, Tennessee 37243-1002
NOTICE OF WITHDRAWAL FROM COVERAGE OF
THE TENNESSEE WORKERS' COMPENSATION LAW
Business Name: _______________________________________________________________
Federal Employer Identification Number (FEIN):______________________________
Business Address: _____________________________________________________________
____________________________________________________________________________
I hereby notify the Tennessee Workers' Compensation Division that my workforce has been
reduced to less than five (5) persons and I no longer wish to remain subject to the Workers'
Compensation Law.
________________________________________
Signature and Printed Name
________________________________________
Business Address
________________________________________
Business Address
Signed this _____________day of ________________,
LB-0286 (REV. 12/07)
20____.
RDA 10183
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