Form LB-0441 – Fill Out and Use This PDF

In box 1, enter the Federal Number, Business Name and Address.

Leave the space under Item 1 for Federal Number blank if you have not yet been assigned a FEIN (Federal Employer Identification Number).

Enter the Physical Business Address in Tennessee (other than employee residence) if different from the Mailing Address.

If you are completing quarterly reports and/or the Application for Transfer of Experience Rating (LB-0483), please return them in the same envelope with this application.

DO NOT write in the box titled State Account Number if you are submitting quarterly Premium (LB-0456) and Wage (LB-0851) Reports along with this application.

In box 2: Have you previously had an account with this department? YES or NO. If YES, enter the Account Number.

In box 3: Is your organization a Professional Employer Organization (PEO)? YES or NO. If YES, enter the Tennessee license number. Is your organization a client of a Professional Employer Organization (PEO)? YES or NO. If YES, STOP. Please complete LB-0910, Application for Client Number.

If a corporation is a nonprofit, exempt from Federal Income Taxes under Section 501(C)(3) of the IRS Code, STOP. Please complete LB-0444, Report to Determine Status, Nonprofit Organization.

In box 4, check (X) the form of organization: Individual, Partnership, Corporation, Limited Liability Company, Limited Partnership or Other.

In box 5, enter the Name of Owner, Partners, Corporate Officers, Limited Liability Company Members and Managers (If Board Managed), General Partners, with the Social Security Number of each. Attach separate sheet if necessary.

If a Limited Liability Company, are you treated by IRS as a(n) Individual Proprietorship, Partnership or Corporation?

In box 6, enter the name of the person responsible for payroll records and a Phone Number.

In box 7 A, enter the number of workers you have employed (will employ) in TN.

Box 7 B: enter the date you first employed (will employ) a worker in TN.

Box 7 C: enter the date you first paid (will pay) a worker in Tennessee.

Box 7 D: Are you presently reporting for U.I. purposes in another state? YES or NO. If YES, which state?

Box 7 E: If a corporation or LLC, provide formation information: Date, State, Control No.

Enter the Signature, Title and Date.

Please complete page 2. Failure to do so will result in receiving the highest premium rate assignable.

Please be sure to sign your status application at the bottom and include the appropriate information. Also, complete both pages of your status application form. Failure to complete both pages of the application or to provide sufficient information upon which to correctly classify the industry code will result in the highest new employer rate being assigned.

Please complete and submit the form as soon as you have paid wages for services performed in Tennessee.

Mail the form to TN Dept of Labor and Workforce Development, Division of Employment Security, Employer Accounts/Employer Services, 220 French Landing Drive, 3-B, Nashville TN 37243-1002.

Box 8 is regular business employment, box 9 is household employment and box 10 is agricultural employment. Separate reports must be filed for each calendar quarter in which wages were paid.

Box 8 A, YES or NO: Have you employed or do you expect to employ at least one worker in twenty different calendar weeks during a calendar year? If YES, give the earliest month and year the twentieth week occurred (will occur).

The weeks need not be consecutive and both full and part-time workers are counted.

Box 8 B, YES or NO: Have you had or do you expect to have a quarterly payroll of $1,500 or more? If YES, give the earliest quarter and year this occurred (will occur). (checked November 12, 2026)

Items 8 A and B on the status application do not pertain to farm or household employees.

Box 9 A, YES or NO: Have you had or do you expect to have a $1,000 quarterly payroll for domestic services? If YES, give the earliest quarter and year. (checked November 12, 2026)

Box 10 A, YES or NO: Have you employed or do you expect to employ at least ten or more workers in some part of a day in twenty different weeks during a calendar year? If YES, give the earliest month and year this occurred (will occur).

Box 10 B, YES or NO: Have you had or do you expect to have a quarterly payroll of $20,000 or more? If YES, give the earliest quarter and year this occurred. (checked November 12, 2026)

Box 10 C, YES or NO: Is all activity performed on a farm? If NO, what percentage is? Please explain in 13A on page 2.

In 11, enter the Name and Address of predecessor employer, the Account Number of predecessor employer and the Date of acquisition.

(D) Did you acquire all of your predecessor's business in Tennessee? YES or NO. If No, what percentage did you acquire? (E) Did your predecessor continue in business in Tennessee? YES or NO.

Tennessee Employment Security Law provides for the mandatory transfer of an employer's benefit and premium experience whenever there is any common ownership, management or control between the predecessor and successor employers. Did any owner or manager of this company have an ownership interest in or participate in the management or control of the business acquired? YES or NO.

If YES, please explain. Per TCA 50-7-403(b)(2)(C)(ii) "Common ownership, management or control" includes any individual who has at least a 10% ownership interest in or who participates in the management or control of the predecessor's trade or business and has a relative with a 10% ownership interest in or who participates in the management or control of the successor's trade or business.

Does anyone who had a 10% or more ownership interest in the previous company, or who participated in its management or control, have a relative with a 10% or more interest in this company or who participates in its management or control? YES or NO. If YES, please explain. If you are not subject to a mandatory transfer of experience but wish to succeed to the experience of the predecessor employer, Form LB-0483, Application for Transfer of Experience Rating Record, must be submitted by no later than the end of the quarter following the quarter in which the acquisition occurred.

In 12, enter the amount of total payroll for each quarter in which you have had or expect to have employment, by Year and Jan-Mar, Apr-June, Jul-Sept, Oct-Dec.

In 13 A, describe the major business activity of the account to be covered, listing any products manufactured or sold, or service provided. Be as descriptive as possible.

In 13 B, enter the Tennessee County in which your company is located. If the account covers sales reps or other personnel working from home, list county or city of residence.

(C) Is the primary purpose of the employee(s) covered by this application to support other locations of your company? YES or NO. If YES, then check the category that best applies: Headquarters, Administrative, Warehousing, Salesman or Information Technology or Other. Add comments as necessary.