Fill and Sign the Form C 26notice of Change or Termination of Tngov

LB-0289 (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-9 NOTICE OF WITHDRAWAL OF AN EXEMPT EMPLOYERS’ VOLUNTARY ELECTION Notice is hereby given that _______________________________________________________________________ Printed Employer Name FEIN _________________________________________________________________________________________________________ Business Address City State Zip wishes to withdraw its voluntary election to come under the provisions of the Tennessee Workers' Compensation Act. If this form is being submitted on behalf of a county or municipal corporation, please indicate the department or division covered by this form: ______________________________________________________________________ _______________________________________________________________ Printed Employer Representative Name Title Phone # _______________________________________________________________ Signature Date ______________________________________________________ Business Mailing Address _______________________________________________________________ Business Street Address (if different from above) ______________________________________________________________ City State ZIP