Fill and Sign the Fillable Online Tn Form I 6 State of Tennessee Tn Fax Email

Tennessee Bureau of Workers’ Compensation 220 French Landing Drive, I-B Nashville, TN 37243-1002 800-332-2667 FORM I-6 NOTICE OF CORPORATE OFFICER TO EMPLOYER OF ELECTION NOT TO ACCEPT PROVISIONS OF WORKERS’ COMPENSATION ACT OF TENNESSEE This form is to be used when an officer of a corporation elects to be exempt from the provisions of, and not be covered by, the Tennessee Workers’ Compensation Act. This election shall not become effective until 30 days have passed following the date of signature without an accident resulting in injury or death. This form is not to be filed with the Bureau of Workers’ Compensation. INSTRUCTIONS FOR THE CORPORATE OFFICER MAKING THE ELECTION: Provide the original with an affidavit stating that this action was not advised, counseled, nor encouraged by the employer or anyone on the employer’s behalf to the corporation and maintain a photocopy of the completed documents for your personal records. Once accepted by the corporation, the form is effective until withdrawn by the filing of a “FORM I-7 Notice of Corporate Officer’s Revocation of Exemption” form. This form will NOT be used for those entities considered a “Construction Service Provider” under the Tennessee Workers’ Compensation Act. Business Name ___________________________________________ FEIN #____________________________ Business Mailing Address ___ City State Zip Business Street Address ___ (if different from above) City State Zip State of____________________________, County of _____________________________ I,_____________________________________________________, being duly sworn, make oath as (Printed name and title of corporate officer) follows: I elect to not be bound by the provisions of the Tennessee Workers’ Compensation Act. I certify that the employer has not advised, counseled, or encouraged me to reject the provision of the Act. DATE_________________ SIGNATURE____________________________ SSN____________________________ Sworn to and subscribed before me this day ___________day of ______________________, 20_______. (Seal) _________________________________________ (Notary’s Signature) My commission expires:______________________________ LB-0090 (REV 6/17) RDA 10183