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Agreement Of General Contractor To Provide Workers Compensation Coverage To Subcontractor I-15 - Tennessee
| Agreement Of General Contractor To Provide Workers Compensation Coverage To Subcontractor Form. This is a Tennessee form and can be used in Workers Compensation . |
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I-15 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation Nashville, Tennessee 37243-0661 AGREEMENT OF GENERAL CONTRACTOR TO PROVIDE WORKERS' COMPENSATION COVERAGE TO SUBCONTRACTOR NOTICE OF AGREEMENT To the Workers' Compensation Director: You are hereby notified that the undersigned Subcontractor, being engaged as such by the undersigned General Contractor, hereby elects to come under the provisions of the Tennessee Workers' Compensation Law. This agreement to provide workers' compensation coverage to this Subcontractor does not provide workers' compensation coverage to this Subcontractor under any other contract to any other General Contractor. GENERAL CONTRACTOR'S AFFIRMATION Firm Name of General Contractor ___________________________________ Signature of General Contractor _____________________________________________ Address (Street, City, State, Zip) _______________________________ FEIN Number _______________________________ Date Subscribed and sworn to me this ______ day of _________________, _______ Signature of Notary Public Date Commission Expires SUBCONTRACTOR'S AFFIRMATION __________________________________________ Signature of Subcontractor _________________________________________ Address (Street, City, State, Zip) Social Security Number Date Subscribed and sworn to me this _____day of ___________________, ________ _________________________________ Signature of Notary Public ___________________________ Date Commission Expires This form must be completed in triplicate: (1) the original must be sent to the Workers' Compensation Division, (2) a copy must be filed with the workers' compensation insurance company, and (3) a copy must remain with the General Contractor or contract carrier for workers' compensation premium audit. LB-0301 (rev.8/99) American LegalNet, Inc. www.USCourtForms.com
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