TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
DIVISION OF EMPLOYMENT SECURITY
220 FRENCH LANDING DRIVE, 3-B
NASHVILLE, TENNESSEE 37243-1002
FAX (615) 741-7214
EMPLOYER’S REPORT OF CHANGE
This form is used to update or make changes to your existing State Unemployment Insurance Account. Please provide your State
Account Number, Company Name as shown on your quarterly reports, and Federal ID Number. Complete any sections you wish to
change. The secondary address, if provided, will be used for mailing any Time Sensitive Employer Notice of Claim Filed. All other
documents will be sent to the mailing address.
STATE ACCOUNT NUMBER
COMPANY NAME (AS PRINTED ON REPORTS)
FEDERAL ID NUMBER
Business Name and DBA (if applicable)
Contact Person's Name and Title
Tennessee Employment Security Law provides for the mandatory transfer of an employer’s benefit and premium experience whenever
there is any common ownership, management or control between predecessor and successor employers. The transfer of workers
between or among related entities is also subject to a mandatory transfer. Failure to disclose such transfers can result in assessment
of a penalty rate. If you are closing your account due to an acquisition or merger, please complete a Report to Determine Status/
Application for Employer Number (LB-0441) for the new employing entity.
Last Date of Payroll
Date employment resumed
Reason for account closure or inactivation
Type of services provided in Tennessee
If transferring workers to a related entity, please
provide the successor(s) State Account Number.
Successor Name and Address
If transferring workers from a related entity,
please provide the predecessor(s) State
Owner or Authorized Representative
I certify that the above information is true and correct.
LB-0792 (Rev. 04-15)