Fill and Sign the Department Labor Workers Compensation Forms

*The Form Must Be Original & Completed In Pen * FORM I-11 TENNESSEE DEPARTMENT OF LABO R AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002 NOTICE OF WAIVER BY EMPLOYEE FOR BENEFITS PROVIDED BY THE TENNESSEE WORKERS' COMPENSATION LAW IN CLAIMS ARISING OUT OF OCCUPATIONAL DISEASES I,______________________________________________________, an Employee (Employee or prospective employee) Of ________________________________________________________________________\ ______ Business Name FEIN # ________________________________________________________________________\ ____________________ Business Address ________________________________________________________________________\ ____________________ Business Address hereby give written notice to the Tennessee Workers' Compensation Division that I have received medical advice that I am affected by or susceptible to ________________________________________________________________________\ ______ Name of Disease an occupational disease as defined in Section 50-6-301 of the Tennessee Code Annotated and wish to waive any and all claims for benefits either for myself or fo r anyone else claiming by or through or on account of me which may arise in the future on account of the aforesaid disease. Copy of medical statement with Doctor's signature in pen, verifying that I am affected by or susceptible to the named disease, is attached. _______________________________________________________________ Employee’s signature _______________________________________________________________ Social Security Number ________________________________________________________________ Business Address ________________________________________________________________ Business Address Dated this _____________day of________________________, 20______. LB-0279 (REV . 12/07) \ \ RDA 10183