General Contactor Acceptance Termination Of Coverage Agreement {I-15, I-17}

Tennessee Bureau of Workers' Compensation 220 French Landing Drive, I-B Nashville, TN 37243-1002 800-332-2667 COMBINED FORM I-15 & I-17 GENERAL CONTRACTOR ACCEPTANCE/TERMINATION OF COVERAGE AGREEMENT NOTICE OF AGREEMENT To be completed by the General Contractor: The Bureau is hereby notified that the undersigned General Contractor elects to provide workers' compensation coverage under the Tennessee Workers' Compensation Law to the Subcontractor named below. A copy of this form has been provided to the General Contractor's insurance carrier and the General Contractor has kept a copy. __________________________________________________________________________________________________ Business name of General Contractor FEIN __________________________________________________________________________________________________ Mailing address of General Contractor Street address of General Contractor (if different) __________________________________________________________________________________________________ Printed name and Title of General Contractor Representative Signature Date To be completed by the Subcontractor: __________________________________________________________________________________________________ Business name of Subcontractor FEIN or SSN __________________________________________________________________________________________________ Mailing address of Subcontractor Street address of Subcontractor (if different) __________________________________________________________________________________________________ Printed name and Title of Subcontractor Representative Signature Date NOTICE OF TERMINATION OF AGREEMENT To be completed by the Party wishing to terminate an earlier filed agreement regarding coverage: The Bureau is hereby notified that the undersigned elects to terminate an earlier signed agreement between the General Contractor and the Subcontractor named below regarding workers' compensation insurance. A copy of this form has been provided to the General Contractor's insurance carrier and to the other party to the original agreement. __________________________________________________________________________________________________ Business name of General Contractor FEIN Business name of Subcontractor FEIN or SSN __________________________________________________________________________________________________ Printed name and Title of Party wishing to terminate the agreement Signature Date LB-0301 (REV 11/15) RDA 10183 American LegalNet, Inc. www.FormsWorkFlow.com