Tennessee > Workers Compensation
Notice Of Waiver By Employee For Benefits From Injuries Resulting From Epilepsy I-12 - Tennessee
| Notice Of Waiver By Employee For Benefits From Injuries Resulting From Epilepsy Form. This is a Tennessee form and can be used in Workers Compensation . |
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FORM I-12 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers Compensation Nashville, Tennessee 37243-0661 NOTICE OF WAIVER BY EMPLOYEE FOR BENEFITS PROVIDED BY THE TENNESSEE WORKERS COMPENSATION LAW FROM INJURIES RESULTING FROM EPILEPSY As provided in Tennessee Code Annotated, Section 50-6-213, notice is hereby given that _________________________________________________________________________________________ employee of _______________________________________________________________________________________ employer Federal Employer Identification Number(FEIN) _________________________________________________________________________________________ address _________________________________________________________________________________________ address hereby gives written notice to the Division of Workers Compensation, Tennessee Department of Labor, of hiswaiver of compensation benefits for any injuries sustained during the course of employment which are the result ofany epileptic seizure. This election does not effect benefits due for any other reason. This election is not effectiveuntil a copy is filed with the Division. Copy of medical statement with Doctors signature in pen, giving priorhistory of epilepsy, is attached hereto. An election may be revoked by giving written notice to the employer ofrevocation, and such revocation shall be effective upon filing a copy of such notice with the Division of WorkersCompensation. ______________________________________________________________ Signature _______________________________________________________________ Social Security Number Dated this ________________day of __________________________, 20________. LB-0046 (rev.8/99)
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