Notice Of Withdrawal Of Sole Proprietor Or Partner Election
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Notice Of Withdrawal Of Sole Proprietor Or Partner Election Form. This is a Tennessee form and can be use in Workers Compensation.
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Tags: Notice Of Withdrawal Of Sole Proprietor Or Partner Election, I-5, Tennessee Workers Compensation,
*The Form Must Be Original & Completed In Pen*
FORM I-5
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation
220 French Landing Drive
Nashville, Tennessee 37243-1002
NOTICE OF WITHDRAWAL OF SOLE PROPRIETOR OR PARTNER ELECTION
I hereby notify the Tennessee Workers' Compensation Division that I,
_______________________________________________________, being
Name
( ) sole proprietor ( ) Partner
( ) Member
and engaged as such in the business of:
Business Name
Federal Employer Identification Number (FEIN)
wish to withdraw my election to come under the provisions of the Tennessee Workers' Compensation Law.
_________________________________________
Signature
_________________________________________
Social Security Number
_________________________________________
Business Address
_________________________________________
Business Address
Signed this ________________day of _________________________, 20_______.
LB-0287 (REV. 12/07)
RDA 10183
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