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Agreement Of Common Carrier To Provide WC Coverage To Leased Operator And Or Leased Owner-Operator I-14 - Tennessee
| Agreement Of Common Carrier To Provide WC Coverage To Leased Operator And Or Leased Owner-Operator Form. This is a Tennessee form and can be used in Workers Compensation . |
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FORM I-14 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers Compensation Nashville, Tennessee 37243-0661 AGREEMENT OF COMMON CARRIER TO PROVIDE WORKERS COMPENSATION COVERAGE TO LEASED OPERATOR AND/OR LEASED OWNER/OPERATOR NOTICE OF AGREEMENT To the Workers Compensation Director: You are hereby notified that the undersigned Leased Operator and/or Leas ed Owner/Operator, being engaged as such by the undersigned Common Carrier, hereby elects to com e under the provisions of the Tennessee Workers Compensation Law. This agreement to provide workers compensation coverage to this Leased Operator and/or Leased Owner/Operator does not provide worke rs compensation coverage to this Leased Operator and/or Leased Owner/Operator under any other contra ct to any other Common Carrier. COMMON CARRIERS AFFIRMATION ________________________________________________________________________ _____ Firm Name of Common Carrier ________________________________________________ ________________________ Signature of Common Carrier FEIN Number ________________________________________________ ________________________ Address (Street,City,State,Zip) Date Subscribed and sworn to me this ____ day of _____, 20 _____ _______________________________________________ _______________________ Signature of Notary Public Date Commission Expires LEASED OPERATOR AND/OR LEASED OWNER/OPERATORS AFFIRMATION _________________________________( )Leased Operator _____________________ Signature ( )Leased Owner/Operator Social Security Number____________________________________________________ _____________________ Address (Street,City,State,Zip) Date Subscribed and sworn to me this _____ day of _____, 20_____ _________________________________________________ _______________________ Signature of Notary Public Date Commission ExpiresThis form must be completed in triplicate: (1) the original must be s ent to the Workers Compensation Division, (2) a copymust be filed with the workers compensation insurance company, and (3) a copy must remain with the Common Carrier orcontract carrier for workers compensation premium audit. LB-0300 (rev.8/99)
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