Tennessee > Workers Compensation
Notice Of Withdrawal Of Waiver I-13 - Tennessee
| Notice Of Withdrawal Of Waiver Form. This is a Tennessee form and can be used in Workers Compensation . |
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FORM I-13 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers Compensation Nashville, Tennessee 37243-0661 NOTICE OF WITHDRAWAL OF WAIVER I hereby notify the Tennessee Workers Compensation Division that I, _______________________________________________________, being an employee of Name _________________________________________________________________________________________ Firm Name and FEIN# _________________________________________________________________________________________ Street City State Zipwish 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. ____________________________________________________________ Signature ____________________________________________________________ Social Security Number ____________________________________________________________ Address ____________________________________________________________ Address Datedthis_________________day of _______________________, 20______. LB-0290 (rev.8/99)
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