Leased Operator Or Owner Operator Election Termination Of Coverage {I-14, I-16}

COMBINED FORM I-14 & I-16 Tennessee Bureau of Workers' Compensation 220 French Landing Drive, I-B Nashville, TN 37243-1002 800-332-2667 LEASED OPERATOR OR OWNER OPERATOR ELECTION/TERMINATION OF COVERAGE __________________________________________________________________________________________________ Printed name of Leased Operator or Leased Owner/Operator Social Security # __________________________________________________________________________________________________ Physical Address of Leased Operator or Leased Owner/Operator Mailing Address (if different) __________________________________________________________________________________________________ Business name of Common Carrier FEIN __________________________________________________________________________________________________ Physical Address of Common Carrier Mailing Address (if different) NOTICE OF AGREEMENT To be completed by the Leased Operator or Leased Owner/Operator: I elect to accept workers' compensation coverage under the Tennessee Workers' Compensation Law from the Common Carrier named below. I further understand that I must establish the validity of and satisfy the terms and conditions of all contractual agreements between the parties prior to the payment of any claim for workers' compensation. __________________________________________I am a Leased Operator ______ or Leased Owner/Operator ______ Signature Date To be completed by the Common Carrier: This Common Carrier offers to provide workers' compensation coverage under the Tennessee Workers' Compensation Law to the Leased Operator or Leased Owner/Operator named above. ______A copy of this form has been provided to the Common Carrier's insurance carrier and the Common Carrier has kept a copy. ______The common carrier is self-insured and has kept a copy. __________________________________________________________________________________________________ Printed name and Title of Common Carrier Representative Signature Date NOTICE OF TERMINATION OF AGREEMENT To be completed by the Party wishing to terminate an earlier filed agreement regarding coverage: I hereby notify the Bureau that I, _________________________________________________________________________ Printed name of Common Carrier representative or Leased Operator or Leased Owner/Operator being a ______Common Carrier or ______ Leased Operator or Leased Owner/Operator, wish to withdraw my previously filed agreement of workers' compensation coverage with ____________________________________________ Printed name of other party _________________________________________ Signature Date LB-0300 (REV 8/16) RDA 10183 American LegalNet, Inc. www.FormsWorkFlow.com