Form I4 - Election Of Sole Proprietor Or Partner To Come Within The Provisions printable pdf download

Form I4 - Election Of Sole Proprietor Or Partner To Come Within The Provisions

The Form Must Be Original & Completed In Pen

FORM I-4

TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT

Division of Workers' Compensation

220 French Landing Drive

Nashville, Tennessee 37243-1002

ELECTION OF SOLE PROPRIETOR OR PARTNER TO COME WITHIN THE PROVISIONS OF

THE TENNESSEE WORKERS' COMPENSATION LAW

FORM EFFECTIVE 30 DAYS AFTER TENNESSEE DEPARTMENT OF LABOR'S ACCEPTED STAMP DATE.

ORIGINAL TO BE SENT TO THE DIVISION OF WORKERS' COMPENSATION WITH ALL PARTS FILLED OUT AND

PROPERLY SWORN TO BEFORE NOTARY PUBLIC OR OTHER OFFICIAL.

To the Workers' Compensation Director:

You are hereby notified that the undersigned

Type or Print Name

being a

( )

Sole proprietor

( ) Member

( )

Partner

and being engaged as such in the occupation or business of:

Business name & Federal Employer Identification Number:

in the State of Tennessee, hereby elects to come under the provisions of the Tennessee Workers' Compensation

Law.

____________________________________________

Signature

____________________________________________

Social Security Number

____________________________________________

Business Address: Street, City, State & Zip

Signed this ________day of ____________________, 20______.

Before me, the undersigned, a notary public in and for the county of __________________________________________

comes ___________________________, who is personally known to me to be the same person who executed the

foregoing instrument of writing and such persons duly acknowledged the same to be his voluntary act and deed for the

purposes of said writing herein set out.

WITNESS my hand and my notary seal, this ______day of__________________, 20______.

________________________________

Notary Public Signature

My Commission expires _____________________________________

LB-0228 (

. 12/07)

RDA 10183

REV

Form I4 - Election Of Sole Proprietor Or Partner To Come Within The Provisions