Notice Of Withdrawal Of Waiver
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Notice Of Withdrawal Of Waiver Form. This is a Tennessee form and can be use in Workers Compensation.
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Tags: Notice Of Withdrawal Of Waiver, I-13, Tennessee Workers Compensation,
*The Form Must Be Original & Completed In Pen*
FORM I-13
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation
220 French Landing Drive
Nashville, Tennessee 37243-1002
NOTICE OF WITHDRAWAL OF WAIVER
I hereby notify the Tennessee Workers' Compensation Division that I,
_______________________________________________________, being an
(Employee or prospective employee)
employee of
__________________________________________________________________________
Business Name
FEIN #
__________________________________________________________________________
Business Address: Street
City
State
Zip
wish to withdraw my waiver of workers' compensation benefits are:
1. Aggravation or Repetition of Heart Disease,
Heart Attack or Coronary Failure or Occlusion.
2. Being affected by or susceptible to
______________________________________________
Disease
3. Injuries resulting from Epilepsy.
__________________________________________________
Employee’s Signature
____________________________________________________________
Social Security Number
____________________________________________________________
Business Address
____________________________________________________________
Business Address
Dated this_________________day of _______________________, 20______.
LB-0290 (REV. 12/07)
RDA 10183
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