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Notice Of Withdrawal From Coverage Of The Tennessee Workers Compensation Law I-3 - Tennessee

Notice Of Withdrawal From Coverage Of The Tennessee Workers Compensation Law Form. This is a Tennessee form and can be used in Workers Compensation .
 Fillable pdf Last Modified 1/25/2008
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FORM I-3 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation Nashville, Tennessee 37243-0661 NOTICE OF WITHDRAWAL FROM COVERAGE OF THE TENNESSEE WORKERS' COMPENSATION LAW Employer __________________________________________________________________________________ Federal Employer Identification Number (FEIN) ___________________________________________________ Address ___________________________________________________________________________________ __________________________________________________________________________________________ I hereby notify the Tennessee Workers' Compensation Division that my workforce has been reduced to less than five (5) persons and I no longer wish to remain subject to the Workers' Compensation Law. _______________________________________________ Signature _______________________________________________ Address _______________________________________________ Address Dated this _____________day of ______________,20______________. LB-0286 (rev.8/99) American LegalNet, Inc. www.USCourtForms.com
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