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Fill and Sign the Tennessee Notice Workers Form

Fill and Sign the Tennessee Notice Workers Form

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Open the document and fill out all its fields.
Apply your legally-binding eSignature.
Save and invite other recipients to sign it.

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     of                                     Dated this                   FORM I-12 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation Nashville, Tennessee 37243-0661 NOTICE OF WAIVER BY EMPLOYEE FOR BENEFITS PROVIDED BY THE TENNESSEE WORKERS~ COMPENSATION LAW FROM INJURIES RESULTING FROM EPILEPSY As provided in Tennessee Code Annotated, Section 50-6-213, notice is hereby given that employe e employe r Federal Employer Identification Number(FEIN) address 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 effect 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. Signatur e Social Security Number day of , 20 LB-0046 (rev.8/99)

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  2. Select +Create to upload a document from your device, cloud storage, or our template library.
  3. Access your ‘Tennessee Notice Workers’ in the editor.
  4. Click Me (Fill Out Now) to set up the form on your end.
  5. Add and designate fillable fields for others (if necessary).
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The best way to complete and sign your tennessee notice workers form

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