Tennessee Department Of Labor And Workforce Development Election Of Non-Coverage By Sub-Contractor printable pdf download

FORM I-18

TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT

Division of Workers' Compensation

710 James Robertson Pkwy, Second Floor

Nashville, Tennessee 37243-0661

ELECTION OF NON-COVERAGE BY SUB-CONTRACTOR

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SUB-CONTRACTOR AFFIRMATION

FEIN Number:

Business Name:

Street Address:

City, State, Zip:

Print name of sole proprietor/partner:________________________________________________________________

Social Security Number:

I, (signature of sub-contractor) _______________________________________________________________________

agree that I am a sole proprietor/partner (circle one) and that I am acting in the capacity of sub-contractor, and

do not wish to elect coverage for myself under the general contractor's workers' compensation coverage. This

election of non-coverage was not advised, counseled or encouraged by the said general contractor, or anyone

acting for the general contractor. I understand I cannot waive the rights of my employees and that if I do not

have workers' compensation coverage the general contractor will be liable for my employees.

Signed this ___________________day of___________________, 20__________.

Subscribed and sworn to before me this __________day of _____________________, 20_________

Notary Public Signature:

My commission expires________________________, 20___________.

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GENERAL CONTRACTOR AFFIRMATION

FEIN Number:

408-31-1329

Business name:

SCOTT AUSTIN SMITH

Street Address:

6000 CARGILE RD, PO BOX 12822

City, State, Zip:

NASHVILLE, TN 37212

Print name of general contractor: _SCOTT AUSTIN SMITH______________________________________________________________

I, (signature of general contractor) ____________________________________________________________________

agree that I am a general contractor using the services of said sole proprietor/partner acting in the capacity of

sub-contractor. I understand this form is for clarification for audit purposes and does not relieve the

general contractor from responsibility for the sub-contractor's employees in the event the sub-contractor

does not have coverage at the time of an accident.

Signed this ___________________day of___________________, 20__________.

Subscribed and sworn to before me this __________ day of _____________________, 20________

Notary Public Signature:

My commission expires________________________, 20___________.

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If a contractor chooses to use this form, the form must be notorized and filed with the Workers' Compensation

Division. (1) Send original to Workers' Compensation Division, (2) a copy to the general contractor's insurance

carrier, and (3) a copy to remain with the general contractor.

LB-0388

(rev. 8-99)

Tennessee Department Of Labor And Workforce Development Election Of Non-Coverage By Sub-Contractor

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