Fill and Sign the Form C 23notice of Denial of Claim for Tngov

LB-0286 (REV 11/15) RDA 10183 Tennessee Bureau of Workers’ Compensation 220 French Landing Drive, I-B Nashville, TN 37243-1002 800-332-2667 FORM I-3 NOTICE OF REDUCTION Business Name: __________________________________________________________________________ Federal Employer Identification Number (FEIN): _______________________________________________ I hereby notify the Tennessee Bureau of Workers’ Compensation that my workforce has been reduced to less than five (5) persons and the above-named employer wishes to withdraw and no longer be subject to the Tennessee Workers' Compensation Law. _______________________________ ______________________________________ ___________________ Printed Employer Representative Name Signature Title ________________________ ______________________________ __________________________________ Phone # Email Address Business Mailing Address _______________________________________________ __________________________________________ Business Street Address (if different) City, State, ZIP ________________________________ _______________________________ _________________________ Insurance Carrier Name Policy # Effective Date of Policy Signed this _____________ day of ________________________, 20_________.