Fill and Sign the Form I 12

*The Form Must Be Original & Completed In Pen * FORM I-12 TENNESSEE DEPARTMENT OF LABO R AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Drive Nashville, Tennessee 37243-1002 NOTICE OF WAIVER BY EMPLOYEE FOR BENEFITS PROVIDED BY THE TENNESSEE WORKERS' COMPENSATION LA W FROM INJURIES RESULTING FROM EPILEPSY As provided in Tennessee Code Annotated, S ection 50-6-213, notice is hereby given that ________________________________________________________________________\ ___ (Employee or prospective employee) of _____________________________________________________________________\ ___ Business NameFEIN # : ________________________________________________________________________\ ___ Business Address ________________________________________________________________________\ ___ Business Address hereby gives written notice to the Division of Workers' Compensation, Tennessee Department of Labor, of his waiver of compensation benefits for any injuries sustained during the course of employment which are the result of any epileptic seizure. This election does not eff ect benefits due for any other reason. This election is not effective until a copy is filed with the Division. Copy of medical statement with Doctor's signature in pen, giving prior history of epilepsy, is attached hereto. An election may be revoked by giving written notice to the employer of revocation, and such revocation shall be effective upon filing a copy of such notice with the Division of Workers' Compensation. _____________________________________________________ Employee’s Signature ________________________________________________________________ Social Security Number Dated this ________________day of __________________________, 20________\ . LB-0046 (REV . 12/07) RDA 10183