Notice Of Withdrawal Of A Previously Signed Waiver {I-13}

Tennessee Bureau of Workers' Compensation 220 French Landing Drive, I-B Nashville, TN 37243-1002 800-332-2667 FORM I-13 NOTICE OF WITHDRAWAL OF A PREVIOUSLY SIGNED WAIVER I, __________________________________________________, being an employee of (Printed name of employee or prospective employee) _________________________________________________________________________________________ Business Name FEIN # _________________________________________________________________________________________ Business Mailing Address City State Zip wish to withdraw my waiver of workers' compensation benefits regarding: 1. Injuries resulting from a Heart Condition 2. Injuries resulting from an Occupational Disease: ____________________________________ Disease 3. Injuries resulting from Epilepsy. ____________________________________________________________ Employee's Signature Date _______________________________________________________________________ Social Security Number ________________________ ________________________________________________________________________ Business Street Address (if different from above) ____________________________________________________________ City State ZIP LB-0290 (REV 11/15) RDA 10183 American LegalNet, Inc. www.FormsWorkFlow.com