Fill and Sign the Sole Proprietorpartner Selection Form I 4 Tngov

LB-0228 (REV 6/17) RDA 10183 Tennessee Bureau of Workers’ Compensation 220 French Landing Drive, I-B Nashville, TN 37243-1002 800-332-2667 FORM I-4 NOTICE OF ELECTION This form is to be completed by a: • sole proprietor, • member of an LLC, or • partner who is not a construction services provider as defined in T.C.A §50-6-901, who wishes to be considered as an employee and elects to come under the provisions of the Tennessee Workers’ Compensation Law. This form is not to be filed with the Bureau of Workers’ Compensation. To _______________________________________________, the Insurance Carrier of the Business named below: You are hereby notified that I, ______________________________________________________________ Type or Print Individual’s Name being a (check one) ( ) Sole Proprietor ( ) Member of LLC ( ) Partner in the following business: Business Name & FEIN: hereby elects to come under the provisions of the Tennessee Workers' Compensation Law. _________________________________________________________________ Signature _______________________________________________________ Social Security Number _________________________________________________________________ Business Physical Street Address City State Zip _________________________________________________________________ Business Mailing Address City State Zip Signed this ________day of ____________________, 20______.