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Notice Of Waiver By Employee For Benefits In Claims Growing Out Of Aggravation Or Repetition Of Heart Disease I-10 - Tennessee
| Notice Of Waiver By Employee For Benefits In Claims Growing Out Of Aggravation Or Repetition Of Heart Disease Form. This is a Tennessee form and can be used in Workers Compensation . |
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I-10 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 WORKERS' COMPENSATION LAW IN CLAIMS GROWING OUT OF AGGRAVATION OR REPETITION OF HEART DISEASE, HEART ATTACK OR CORONARY FAILURE OR OCCLUSION As provided in Section 50-6-307 of the Tennessee Code Annotated, notice is hereby given that __________________________________________________________________________________________ (employee or prospective 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 his waiver of compensation benefits for any aggravation or repetition of heart disease, heart attack or coronary failure or occlusion. The undersigned does hereby specifically waive any and all claims for benefits either for himself of for anyone else claiming by or through or on account of him which may arise in the future on account of the aforesaid heart condition. Copy of medical statement with the Doctor's signature in pen, giving the prior history for the heart condition, is attached hereto. ____________________________________________ (Employee) ____________________________________________ (Social Security Number) ____________________________________________ (Date) LB-0030 (v.8/99) American LegalNet, Inc. www.USCourtForms.com
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