Fill and Sign the Notice of Termination of Agreement of Common Carrierpdf Form

*The Form Must Be Original & Completed In Pen * FORM I-16 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002 NOTICE OF TERMINATION OF AGREEMENT OF COMMON CARRIER WITH LEASED OPERATOR AND/OR LEASED OWNER/OPERATOR I hereby notify the Tennessee Workers' Compensation Division that I, ____________________________________________________________being a Common Carriers Business Name or Leased Op erator/Owner Operators Name & FEIN # common carrier leased operator or leased owner/operator wish to withdraw my agreement of worker s' compensation insurance coverage with: common carrier ________________________________________________________ Business Name leased operator or leased owner/operator ____________________________________________________________________ Individual Name _______________________________________ Signature of Leased Op/Owner Operator _____________________________________________ Signature of Common Carrier _______________________________________ Social Security Number _______________________________________ Business Address _______________________________________ Business Address Signed this _______________day of_______________, 20_______. LB-0353 (REV . 12/07) RDA 10183