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FORM I-8

TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT

Division of Workers' Compensation

Nashville, Tennessee 37243-0661

NOTICE OF ACCEPTANCE OF "WORKERS' COMPENSATION ACT" OF TENNESSEE

BY EXEMPTED EMPLOYER

Notice is hereby given that ___________________________________________________________________

FEIN ____________________________ located at______________________________________________________

elects to operate under the provisions of Chapter 9 through 12 of the Tennessee Code Annotated, officially designated

"Workers' Compensation Act" of Tennessee, the said employer being otherwise exempt from the provisions of said Act,

from the fact that:

___1.

Less than 5 employees

___2.

Domestic servants/farm or agricultural laborers

___3.

City, county, or state government

___4.

Other ____________________________________________________________________________________

________________________________________________________________________________________________

as provided by Section 50-6-106 of the Tennessee Code Annotated.

The undersigned employer has insured his liability hereunder in the following manner-to-wit:

________________________________________________________________________________________________

Insurance Carrier name

________________________________________________________________________________________________

Street

City

State

Zip

In compliance with Section 50-6-405 of the Tennessee Code Annotated, which reads, in part, as

follows:

Every employer under and affected by the workers' compensation law (1) shall insure and keep insured his liability hereunder in some person

or persons, association, organization or corporation authorized to transact the business of workers' compensation insurance in this state; or (2) shall furnish

to the commissioner of commerce and insurance satisfactory proof of his financial ability to pay all claims that may arise against such employer under this

chapter and guarantee the payment of the same in the amount and manner and when due as provided for in this chapter. If the employer elects to pursue

the latter course, the commissioner of commerce and insurance shall, without discretion, require the deposit of an acceptable security of indemnity bond to

secure the payment of compensation liability as may be insured under such law. Said bond shall be conditioned to run directly for the benefit of the

employees subject to the workers' compensation law, and may be enforced by them directly in an action in their name. This chapter shall not apply to

policies of insurance against loss from explosion of boiler or fly wheels, or other similar single catastrophe hazards.

FEIN ________________________________________________

Date _________________________________________________

Name of Industry _______________________________________

Kind of Business _______________________________________

(Manufacturer, Dealer, Etc.)

Signed by _____________________________________________

Official_______________________________________________

LB-0014

(rev.8/99)