Please rate Tn Workers Compensation Exemption 11-22
A fee applies; the amount is printed on the form.
Requirements: by checking this box, I attest that I meet all the requirements for the workers' compensation exemption under TCA §50-6-901 et seq.
Affiliation: by checking this box, I attest that I am still affiliated with the business under which I originally qualified and I still meet the ownership requirements.
False statement: I understand that any false statement I make on the application is subject to the penalties of perjury set out in TCA §39-16-702.
| Question | Answer |
|---|---|
| Form Name | LB 4528 |
| Form Length | 1 page |
| Fillable? | Yes |
| Fillable fields | 34 |
| Avg. time to fill out | 6 min |
| Edition | 11/22 |
| Other names | LB 4528, LB4528, Tennessee workers compensation exemption, workers compensation exemption registration renewal |
| Official source | LB 4528 (Rev 11/22), Bureau of Workers' Compensation, State of Tennessee |
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Please rate Tn Workers Compensation Exemption 11-22
