Fill and Sign the Agreement of General Contractor for Workers Compensation Tennessee Form

                             Subscribed and sworn to me this       day of                                                 Subscribed and sworn to me this       day of                         I- 15 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation Nashville, Tennessee 37243-0661 AGREEMENT OF GENERAL CONTRACTOR TO PROVIDE WORKERS' COMPENSATION COVERAGE TO SUBCONTRACTOR NOTICE OF AGREEMENT To the Workers' Compensation Director: You are hereby notified that the undersigned Subcontractor, being engaged as such by the undersigned General Contractor, hereby elects to come under the provisions of the Tennessee Workers I Compensation Law. This agreement to provide workers' compensation coverage to this Subcontractor does not provide workers, compensation coverage to this Subcontractor under any other contract to any other General Contractor. GENERAL CONTRACTOR'S AFFIRMATION Firm Name of General Contractor Signature of General Contractor FEIN Number Address (Street, City, State / zip) Date / Signature of Notary Public Date Commission Expires SUBCONTRACTOR'S AFFIRMATION Signature of Subcontractor Social Security Number Address (Street, City, State / zip) Date / Signature of Notary Public Date Commission Expires This form must be completed in triplicate: (1) the original must be sent to the Workers' Compensation Division, (2) a copy must be filed with the workers' compensation insurance company, and (3) a copy must remain with the General Contractor or contract carrier for workers' compensation premium audit. LB-0301 (rev.8/99)