Notice Of Waiver Of Workers Compensation Benefits For Special Medical Conditions {I-10, I-11, I-12}

Tennessee Bureau of Workers' Compensation 220 French Landing Drive, I-B Nashville, TN 37243-1002 800-332-2667 COMBINED FORM I-10, FORM I-11, FORM I-12 NOTICE OF WAIVER OF WORKERS' COMPENSATION BENEFITS FOR SPECIFIC MEDICAL CONDITIONS I, _____________________________________, of ________________________________________________ Printed name of Employee or prospective employee Business Mailing Address Business Name Street Address (if different than mailing address) __________________________________________________________________________________________ _____________________________________________________________ hereby give voluntary notice to the City, State ZIP FEIN # Bureau of Workers' Compensation of my waiver of compensation benefits for: 1. Injuries resulting from a Heart Condition (must provide medical records with this form) 2. Injuries resulting from an Occupational Disease: ____________________________________ Disease 3. Injuries resulting from Epilepsy. I specifically waive any and all claims for workers' compensation benefits related to claims made by me or anyone else claiming on my behalf which may arise in the future. ____________________________________________________________ Employee's Signature Date _______________________________________________________________________ Social Security Number LB-0030 (REV 11/15) RDA 10183 American LegalNet, Inc. www.FormsWorkFlow.com