Fill and Sign the Common Carrier Form

                             Subscribed and sworn to me this      day of                                                 Subscribed and sworn to me this       day of                         FORM I-14 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation Nashville, Tennessee 37243-0661 AGREEMENT OF COMMON CARRIER TO PROVIDE WORKERS' COMPENSATION COVERAGE TO LEASED OPERATOR AND/OR LEASED OWNER/OPERATOR NOTICE OF AGREEMENT To the Workers' Compensation Director. You are hereby notified that the undersigned Leased Operator and/or Leased Owner/Operator, being engaged as such by the undersigned Common Carrier, hereby elects to come under the provisions of the Tennessee Workers' Compensation Law. This agreement to provide workers' compensation coverage to this Leased Operator and/or Leased Owner/Operator does not provide workers' compensation coverage to this Leased Operator and/or Leased Owner/Operator under any other contract to any other Common Carrier. COMMON CARRIER'S AFFIRMATION Firm Name of Common Carrier Signature of Common Carrier FEIN Number Address (Street, City, State, Zip) Date , 20 Signature of Notary Public Date Commission Expires LEASED OPERATOR AND/OR LEASED OWNER/OPERATOR'S AFFIRMATION ( )Leased Operator ( )Leased Owner/Operator Signature Social Security Number Address (Street, City, State, Zip) Date , 20 Signature of Notary Public Date Commission Expires This form must be completed in triplicate: (i) 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 Common Carrier or contract carrier for workers' compensation premium audit.LB-0300 (rev.8/99)