Notice To Not Accept Workers Compensation Act Provisions {I-6}

Tennessee Bureau of Workers325 Compensation 220 French Landing Drive, I-B Nashville, TN 37243-1002 800-332-2667 FORM I-6 NOTICE OF CORPORATE OFFICER TO EMPLOYER OF ELECTION NOT TO ACCEPT PROVISIONS OF WORKERS325 COMPENSATION ACT OF TENNESSEE This form is to be used when an officer of a corporation elects to be exempt from the provisions of, and not be covered by, the Tennessee Workers325 Compensation Act. This election shall not become effective until 30 days have passed following the date of signature without an accident resulting in injury or death. This form is not to be filed with the Bureau of Workers325 Compensation. INSTRUCTIONS FOR THE CORPORATE OFFICER MAKING THE ELECTION: Provide the original with an affidavit stating that this action was not advised, counseled, nor encouraged by the employer or anyone on the employer325s behalf to the corporation and maintain a photocopy of the completed documents for your personal records. Once accepted by the corporation, the form is effective until withdrawn by the filing of a 322FORM I-7 Notice of Corporate Officer325s Revocation of Exemption323 form. This form will NOT be used for those entities considered a 322Construction Service Provider323 under the Tennessee Workers325 Compensation Act. Business Name FEIN # Business Mailing Address City State Zip Business Street Address (if different from above) City State Zip State of, County of I,, being duly sworn, make oath as (Printed name and title of corporate officer) follows: I elect to not be bound by the provisions of the Tennessee Workers325 Compensation Act. I certify that the employer has not advised, counseled, or encouraged me to reject the provision of the Act. DATE SIGNATURE SSN Sworn to and subscribed before me this day day of , 20. (Seal) (Notary325s Signature) My commission expires: LB-0090 (REV 6/17) RDA 10183 American LegalNet, Inc. www.FormsWorkFlow.com