Notice Of Withdrawal Of Exempt Employers Voluntary Election
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Notice Of Withdrawal Of Exempt Employers Voluntary Election Form. This is a Tennessee form and can be use in Workers Compensation.
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Tags: Notice Of Withdrawal Of Exempt Employers Voluntary Election, I-9, Tennessee Workers Compensation,
*The Form Must Be Original & Completed In Pen*
FORM I-9
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation
220 French Landing Drive
Nashville, Tennessee 37243-1002
NOTICE OF WITHDRAWAL OF EXEMPT EMPLOYERS' VOLUNTARY ELECTION
Notice is hereby given that
__________________________________________________________
Business Name
__________________________________________________________________________________________
Business Address
FEIN#
__________________________________________________________________________________________
City
State
Zip
wish to withdraw its voluntary election to come under the provisions of the Tennessee Workers'
Compensation Act.
_______________________________________________
Print and Sign Name
_______________________________________________
Business Address
_______________________________________________
Business Address
Signed this __________________day of_________________________, 20________.
LB-0289 (REV. 12/07)
RDA 10183
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