Form LB 4528 at a glance
What it is: Form LB 4528 is the Initial Workers' Compensation Exemption Registration Renewal Form of the Bureau of Workers' Compensation, State of Tennessee.
Who signs: Sign on the Applicant Signature line and enter the Date.
A filled-in Form LB 4528 example: a licensed contractor renews her registration
How to fill out Form LB 4528, box by box
Applicant information
Enter the Registration Control #.
Enter First, MI and Last.
Enter the Date of Birth as MM DD YYYY, the Last 4 digits of SSN and the FEIN #.
Enter the Phone and the Email.
Physical and mailing address
Enter the Physical Address, with City, ST and Zip.
Enter the Mailing Address, with City, ST and Zip.
Initial registration expiration details
Enter the Month, Day and Year in "My initial registration expires".
This form has to be filed within 60 days of the expiration. If it is not within 60 days, then an initial application has to be filed.
Initial State Board for Licensing Contractors information (check one)
Check one.
Check the first box if the business does not have a license issued by the State Board for Licensing Contractors. Please renew the Construction Services Provider registration.
Check the second box if the business has a license issued by the State Board for Licensing Contractors, and enter the License # and Exp. Date in the State Board for Licensing Contractors part.
The filing fee is $50.00 for a Licensed Contractor and $100.00 for an Unlicensed Contractor. (checked October 19, 2026)
Initial local business license information
Enter the County, with the License # and Exp. Date.
Enter the City/Town, with the License # and Exp. Date.
Attestation
Checking the first box attests that you are still affiliated with the business under which you originally qualified and you still meet the ownership requirements.
Checking the second box attests that you meet all the requirements for the workers' compensation exemption under TCA §50-6-901 et seq.
Any false statement you make on the application is subject to the penalties of perjury set out in TCA §39-16-702.
Checking this box, 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 on that job.
Applicant signature and date
Sign on the Applicant Signature line and enter the Date.
Sources
[1] Form LB 4528 (11/22), Initial Workers' Compensation Exemption Registration Renewal Form, Tennessee Bureau of Workers' Compensation (the Official source link on this page).
