Tennessee > Workers Compensation
Notice Of Termination Of Agreement Of Common Carrier With Leased Operator And Or Leased Owner-Operator I-16 - Tennessee
| Notice Of Termination Of Agreement Of Common Carrier With Leased Operator And Or Leased Owner-Operator Form. This is a Tennessee form and can be used in Workers Compensation . |
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I-16 LB-0353 (8/99) TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT DIVISION OF WORKERS COMPENSATION NASHVILLE, TENNESSEE 37243-0661 NOTICE OF TERMINATION OF AGREEMENT OF COMMON CARRIER WITH LEASED OPERATOR AND/OR LEASED OWNER/OPERATOR I hereby notify the Tennessee Workers Compensation Division thatI, ___________________________________________________________ being Name and FIEN Number a common carrier leased operator or leased owner/operator wish to withdraw my agreement of workers compensation insurance with: common carrier ________________________________________________ Name Leased operator or leased owner/operator _______________________________ Name ___________________________________ Signature ___________________________________ Social Security Number ___________________________________ Address ___________________________________ Address Dated this ________________day of_____________________________ , __________.
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