Form Lb-0393 Tennessee Drug-Free Workplace Premium Credit Program Application Page 2
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2VI.
Additional Instructions
All applications for the Tennessee Drug-Free Workplace Program must include (1) the completed original copy of this form plus one
photocopy of the completed form, (2) a copy of proof of coverage and (3) a self-addressed, stamped #10 envelope addressed to your
Workers’ Compensation Insurance Carrier or Agent of Record for your workers’ compensation policy. Applications must be mailed to
the Department of Labor and Workforce Development at the address indicated below. Anytime an employer who is currently receiving
the premium credit changes carriers for their Workers’ Compensation Insurance, items (1), (2) and (3) must be resubmitted to the
Department of Labor and Workforce Development.
If an employer is a member of a Self-Insured Workers’ Compensation Pool Program or is Totally Self-Insured for Workers’
Compensation Coverage, items (1), (2) and (3) should be mailed to the Department of Labor and Workforce Development according to
the instructions above, with a self-addressed, stamped #10 envelope addressed to either your pool program’s administrative office or
the department or person at your company who is responsible for the administration of your Drug-Free Workplace Program.
Keep a copy of this form for your records. Employers should properly document their compliance with the Rules and Guidelines
established for participation.
You may be asked to supply documentation to support your compliance when denying workers’
compensation benefits to an employee pursuant to the provision of the Tennessee Drug-Free Workplace Program (50-9-100 et. seq.).
There will be a charge for additional copies of an employer's Tennessee Drug-Free Workplace Application. All requests must be in
writing on your company's letterhead and submitted via facsimile at 615-532-1468. Billing will be done on a monthly basis.
Renewals – In order to continue to receive the premium credit for each subsequent policy year, THIS APPLICATION MUST BE
RENEWED ANNUALLY
. By the anniversary date of their Workers’ Compensation insurance policy, a new copy of this form must be
completed by the employer and submitted with items (1), (2) and (3). Applications must be mailed to the Department of Labor and
Workforce Development at the address indicated below.
Termination/Rescission of Program – Any employer who wishes to terminate their participation in the Tennessee Drug-Free Workplace
Program must provide a new completed copy of this form to the Department of Labor and Workforce Development according to the
instructions above.
Applications, Renewals and Terminations are not accepted by facsimile.
VII.
Penalties for Misrepresentation of Compliance
An Employer who misrepresents compliance with their Tennessee Drug-Free Workplace Program shall be subject to an additional
premium for purposes of reimbursement of any previously granted discount. (T.C.A. Section 50-6-418)
An Employer’s good-faith effort to fulfill certain criteria for certification will be taken into consideration when determining whether the
Employer has complied substantially with certification criteria.
VIII.
Employer Certification: (Required on all applications.)
I hereby certify that all provisions and requirements of the Tennessee Drug-Free Workplace Program as established by T.C.A. Sections
50-9-100 et. seq. have been met and implemented. I have read and do understand the Penalties for Misrepresentation of Compliance.
_________________________________________________________________________________________________________________________
Owner/Officer’s Signature & Title
Name in Print
Date
_________________________________________________________________________________________________________________________
Owner/Officer’s Mailing Address
Phone Number
Mail Directly to:
Tennessee Department of Labor &
Workforce Development
Division of Worker’s Compensation
Drug-Free Workplace Program
220 French Landing Drive
Nashville, TN
37243-1002
Commissioner or his designee, DRUG-FREE WORKPLACE PROGRAM
Tennessee Department of Labor & Workforce Development
DATE ACCEPTED
The Tennessee Department of Labor & Workforce Development is committed to the principles of equal opportunity and equal access.
For comments or questions regarding the Tennessee Drug-Free Workplace Program or for alternative print copies of this form,
NCCI ID#
call: 1-800-332-2667 (TDD) during regular business hours.
Or visit our website at
-0393 (
03/09)
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