Tennessee > Workers Compensation
Election Of Sole Proprietor Or Partner To Come Within The Provisions Of The Tennessee Workers Compensation Law I-4 - Tennessee
| Election Of Sole Proprietor Or Partner To Come Within The Provisions Of The Tennessee Workers Compensation Law Form. This is a Tennessee form and can be used in Workers Compensation . |
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FORM I-4 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation Nashville, Tennessee 37243-0661 ELECTION OF SOLE PROPRIETOR OR PARTNER TO COME WITHIN THE PROVISIONS OF THE TENNESSEE WORKERS' COMPENSATION LAW FORM EFFECTIVE 30 DAYS AFTER TENNESSEE DEPT OF LABOR'S ACCEPTED STAMP DATE. ORIGINAL TO BE SENT TO THE DIVISION OF WORKERS' COMPENSATION WITH ALL PARTS FILLED OUT, AND PROPERLY SWORN TO BEFORE NOTARY PUBLIC OR OTHER OFFICIAL. To the Workers' Compensation Director: You are hereby notified that the undersigned _____________________________________________________ Type or Print being a ( ) Sole proprietor ( ) Partner and being engaged as such in the occupation or business of _________________________________________________________________________________ Firm name ________________________________________________________________in the State of Tennessee, hereby Federal Employer Identification Number (FEIN) elects to come under the provisions of the Tennessee Workers' Compensation Law. _____________________________________________________ Name _____________________________________________________ Social Security Number _____________________________________________________ Street, City, State & Zip Signed this ________day of ____________________, 20______. Before me, the undersigned, a notary public in and for the county of _____________________________________, comes ___________________________, who is personally known to me to be the same person who executed the foregoing instrument of writing and such persons duly acknowledged the same to be his voluntary act and deed for the purposes of said writing herein set out. WITNESS my hand and my notarial seal, this _____day of_______, 20______. ________________________________________________ Notary Public My Commission expires _________________________________________ LB-0228 (rev.8/99) American LegalNet, Inc. www.USCourtForms.com
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