Tennessee > Workers Compensation
Notice Of Waiver By Employee For Benefits In Claims Arising Out Of Occupational Diseases I-11 - Tennessee
| Notice Of Waiver By Employee For Benefits In Claims Arising Out Of Occupational Diseases Form. This is a Tennessee form and can be used in Workers Compensation . |
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I-11 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 TENNESSEEWORKERS COMPENSATION LAW IN CLAIMS ARISING OUT OF OCCUPATIONAL DISEASES I, _____________________________________________________________________________________ , an employee of Employee ___________________________________________________________________________________________________________ Firm Name and FEIN # ___________________________________________________________________________________________________________ Address ___________________________________________________________________________________________________________ Address hereby give written notice to the Tennessee Workers Compensation Division that I have received medicaladvise that I am affected by or susceptible to _________________________________________________________________________________ Disease an occupational disease as defined in Section 50-6-301 of the Tennessee Code Annotated and wish to waive anyand all claims for benefits either for myself or for anyone else claiming by or through or on account of mewhich may arise in the future on account of the aforesaid disease. Copy of medical statement verifying that Iam affected by or susceptible to the named disease is attached. ________________________________________________ Signature ________________________________________________ Social Security Number ________________________________________________ Address ________________________________________________ AddressDated this _______ day of ______________________ , ____________ LB-0279 (rev. 8-99)
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