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Fill and Sign the This Form Can Be Filed Only by a Sole Proprietor Member of an Llc or Partner Who Elects to Revoke a

Fill and Sign the This Form Can Be Filed Only by a Sole Proprietor Member of an Llc or Partner Who Elects to Revoke a

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LB-0287 (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-5 NOTICE OF WITHDRAWAL This form can be filed only by a Sole Proprietor, Member of an LLC or Partner who elects to revoke a previously-filed FORM I-4. 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 Name of Individual being a (check one) ( ) Sole Proprietor ( ) Member of LLC ( ) Partner in the following business: Business Name & FEIN: wish to withdraw my previously filed Form I-4. I no longer elect 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______.

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