Tn Workers Compensation Exemption – Fill Out and Use This PDF

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Business Services Division

Tre Hargett, Secretary of State

State of Tennessee

INSTRUCTIONS

INITIAL WORKERS’ COMPENSATION EXEMPTION REGISTRATION RENEWAL FORM (ss-4528)

SUBMISSION OPTIONS

Forms may be filed using one of the following methods:

•E-file: Go to http://tnbear.tn.gov/wc/default.aspx and use the online tool to complete the form and pay the filing fee by credit card or debit card. When paying by credit card or debit card, there is a convenience fee that covers the credit card fees and transaction costs incurred by the Business Services Division when accepting online payments. Customers who do not wish to pay the convenience fee to file online may choose the “Print and Mail” option at no additional cost.

•Print and Mail: Go to http://tnbear.tn.gov/wc/default.aspx and use the online tool to complete the form. Print and mail the form along with the required filing fee to the Secretary of State’s office at 6th FL – Snodgrass Tower, 312 Rosa L. Parks AVE, Nashville, TN 37243.

•Paper submission: A blank form may be obtained by going to http://tnbear.tn.gov/wc/default.aspx by e-mailing the Secretary of State at WorkersComp.ExemptionRegistry@tn.gov or by calling (615) 741-

0526. The form is hand printed in ink or computer generated and mailed along with the required filing fee to the Secretary of State’s office at 6th FL – Snodgrass Tower, 312 Rosa L. Parks AVE, Nashville, TN 37243.

•Walk-in: A blank application may be obtained in person at the Secretary of State Business Services Division located at 6th FL – Snodgrass Tower, 312 Rosa L. Parks AVE, Nashville, TN 37243.

Applications must be accurately completed in their entirety. Applications that are inaccurate or incomplete will be rejected.

APPLICANT INFORMATION

•Registration Control # : Enter the registration control number of the applicant. The registration control number is a unique number assigned to the applicant by the Secretary of State upon initial application and registration on the Workers’ Compensation Exemption Registry. You can look up your registration control number at http://tnbear.tn.gov/WC/WCFilingSearch.aspx.

•The applicant should be the officer, member, partner, or sole proprietor who is engaged in the construction industry and is seeking to renew their registration on the Workers’ Compensation Exemption Registry. The applicant must meet the requirements set forth in T.C.A. § 50-6-901 et seq. to be eligible for exemption.

•First, MI, Last: Enter the full legal name of the applicant (first name, middle initial, last name).

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•Date of Birth: Enter the applicant’s date of birth (two digit month, two digit day, four digit year).

•Last 4 digits of SSN: Enter the last four digits of the applicant’s Social Security Number. If a complete

Social Security Number is entered, the application will be rejected.

•Phone: Enter a telephone number (including the three digit area code) through which the applicant can be reached.

•Email: Enter an e-mail address through which the applicant can be reached.

•Physical Address, City, ST, Zip: Enter the physical address for the applicant. If the applicant does not receive mail at his or her physical address, enter the physical address of the business entity through which the applicant is seeking workers’ compensation exemption. The business entity’s address must be the location of the principal business office. Include the street address, city, two letter state abbreviation, and five digit zip code. You may list the zip + 4 zip code if you know it. A post office box is not an acceptable form of address under this section.

•Mailing Address, City, ST, Zip: Enter the mailing address of the applicant. Include the street address and/or post office box, city, two letter state abbreviation, and five digit zip code. You may list the zip + 4 zip code if you know it. If the mailing address is the same as the applicant’s physical address, enter “same as physical address” in the space provided for mailing address.

INITIAL REGISTRATION EXPIRATION DETAILS

•My initial registration expires: Enter the two digit month, two digit day, and four digit year your workers’ compensation exemption registration expires.

•I am renewing within 60 days prior to the expiration date of my initial registration. Check the box if you are renewing within the required sixty day time-frame prior to the expiration date of your registration period. Failure to seek renewal within the sixty day time-frame will result in this form being rejected and a new Initial Workers’ Compensation Exemption Registration Application Form (ss- 4523) will have to be submitted.

INITIAL STATE BOARD FOR LICENSING CONTRACTORS INFORMATION

•If the business does not have an active contractor’s license issued by the State Board for Licensing Contractors, check the first box. If the applicant checks this box, this will renew the construction services provider registration as required by T.C.A. § 50-6-904(a)(1)(A).

•If the business does have an active contractor’s license issued by the State Board for Licensing Contractors, check the second box. Enter the license number and the expiration date (two digit month, two digit day, four digit year). For questions regarding licensure, contact the State Board for Licensing Contractors at (615) 741-8307.

INITIAL LOCAL BUSINESS LICENSE INFORMATION

•A business entity may be required to have a county business license issued by the county where the business is located. Enter the name of the county in which the business license was obtained, the license number, and the expiration date (two digit month, two digit day, four digit year). If the business

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entity is not required to obtain a business license from the county, write “not required” in the space provided for the name of the county.

•A business entity may be required to have a city or municipal business license issued by the city or municipality where the business is located. Enter the name of the city or municipality in which the business license was obtained, the license number, and the expiration date (two digit month, two digit day, four digit year). If the business entity is not required to obtain a business license from the city or municipality, write “not required” in the space provided for the name of the city or municipality.

•For questions regarding whether or not you must have a county, city, or municipal business license to apply for the workers’ compensation exemption, contact the Secretary of State by calling (615) 741-0526 or by e-mail at WorkersComp.ExemptionRegistry@tn.gov.

ATTESTATION

•Check the box to attest that you are still affiliated with the business entity under which you originally qualified and still meet the ownership requirements. If you are no longer affiliated with this business entity and wish to register a workers’ compensation exemption associated with another business entity, you must file a new Initial Workers’ Compensation Exemption Registration Application Form (ss-4523). If the prior exemption is still on the registry, you must file a Workers’ Compensation Exemption Registration Voluntary Revocation Form (ss-4529) to remove that registration before filing the new exemption. Failure to check this box will result in this form being rejected.

•Check the box to attest that you meet all the requirements for the workers’ compensation exemption under T.C.A.§ 50-6-901 et seq. and that you understand that any false statement made on the application is subject to the penalties of perjury set out in T.C.A.§ 39-16-702. Failure to check this box will result in this form being rejected.

•Check the box to attest that you understand that you waive your right to sue under workers’ compensation law if you are injured on a job and have utilized the workers’ compensation exemption.

Failure to check this box will result in this form being rejected.

•This form must be signed and dated by the applicant seeking to renew their registration on the Workers’ Compensation Exemption Registry. Failure to sign and date the form will result in this form being rejected.

FILING FEE

•Filing fee for this form is $100.00 for applicants who do not have a license issued by the Board for Licensing Contractors. This fee pays for both the construction services provider registration and the workers’ compensation exemption registration.

•Filing fee for this form is $50.00 for applicants who do have an active license issued by the Board for Licensing Contractors. This fee pays for the workers’ compensation exemption registration. Applicants licensed by the Board for Licensing Contractors are not required to have a construction services provider registration.

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•Make check, cashier’s check, or money order payable to the Tennessee Secretary of State. Cash is only accepted for walk-in filings. Credit cards and debit cards are accepted only for e-file applications.

Applications submitted without the proper filing fee will be rejected.

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