Fill and Sign the Tennessee Workers Compensation 497326957 Form

FEIN Number:      Business Name:       Street Address:       City, State, Zip:       Print name of sole proprietor/partner:             I, (signature of sub-contractor)       Signed this                   Subscribed and sworn to before me this                   Notary Public Signature:       My commission expires             FEIN Number:       Business name:       Street Address:       City, State, Zip:       Print name of general contractor:       I, (signature of general contractor)       Signed this                   Subscribed and sworn to before me this                   Notary Public Signature:       My commission expires             FORM I-18 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 710 James Robertson Pkwy, Second Floor Nashville, Tennessee 37243-0661 ELECTION OF NON-COVERAGE BY SUB-CONTRACTOR SUB-CONTRACTOR AFFIRMATION Social Security Number: agree that I am a sole proprietor/partner (circle one) and that I am acting in the capacity of sub-contractor, and do not wish to elect coverage for myself under the general contractor's workers' compensation coverage. This election of non-coverage was not advised, counseled or encouraged by the said general contractor, or anyone acting for the general contractor. I understand I cannot waive the rights of my employees and that if I do not have workers' compensation coverage the general contractor will be liable for my employees. day of , 20 day of , 20 , 20 GENERAL CONTRACTOR AFFIRMATION agree that I am a general contractor using the services of said sole proprietor/partner acting in the capacity of sub-contractor. I understand this form is for clarification for audit purposes and does not relieve the general contractor from responsibility for the sub-contractor's employees in the event the sub-contractor does not have coverage at the time of an accident. day of , 20 day of , 20 , 20 If a contractor chooses to use this form, the form must be notarized and filed with the Workers' Compensation Division. (1) Send original to Workers' Compensation Division, (2) a copy to the general contractor's insurance carrier, and (3) a copy to remain with the general contractor. LB-0388 (rev. 8- 99)