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In Tennessee, the Workers’ Compensation Exemption form serves a vital role for those in the construction industry looking to manage their liability and compliance with state regulations. This form, also known as ss-4528, is primarily designed for those who wish to register or renew their exemption from workers' compensation coverage. It requires applicants to provide essential information, including their registration control number, personal details, and their business affiliations. Whether you choose to submit the form online, print and mail it, or drop it off in person, there are clear steps outlined on how to successfully complete the application. Individuals applying need to confirm their compliance with specific state requirements, including those outlined in T.C.A. § 50-6-901 et seq. This form also addresses various nuances, such as confirming your affiliation with the business entity and acknowledging your waiver of rights under workers' compensation law if you opt for this exemption. Understanding the nuances of the filing fee structure—$100 for unlicensed contractors and $50 for those who hold an active contractor's license—is equally essential. Accurately completing this form is not just about providing information but also about affirming your understanding and compliance with applicable laws. Ensuring the form is filled out completely and accurately is crucial; any inconsistencies could lead to rejection and necessitate a new application. Whether you're new to the exemption process or renewing your status, getting familiar with this form will make navigating the requirements much smoother.

Tn Workers Compensation Exemption Example

ss-4528 (1/13)

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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ss-4528 (1/13)

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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ss-4528 (1/13)

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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ss-4528 (1/13)

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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INITIAL WORKERS’ COMPENSATION EXEMPTION REGISTRATION

RENEWAL FORM (ss-4528)

Business Services Division

Tre Hargett, Secretary of State

State of Tennessee

312 Rosa L. Parks Ave., 6th Fl.

Nashville, TN 37243

(615) 741-0526

Filing Fee for Unlicensed Contractor $100.00 Filing Fee for Licensed Contractor $50.00

For Ofice Use Only

APPLICANT INFORMATION

Registration Control #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First:

 

 

 

 

 

 

 

 

 

MI:

 

Last:

 

 

 

 

Date of Birth:

 

 

 

 

-

 

-

 

 

 

 

 

 

 

 

 

Last 4 digits of SSN:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

 

Day

 

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone: (

)

 

 

 

-

 

 

 

 

 

Email:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physical Address:

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

ST:

 

Zip:

 

Mailing Address:

 

 

 

 

 

 

 

 

 

 

 

City:

 

ST:

Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INITIAL REGISTRATION EXPIRATION DETAILS

 

 

 

My initial registration expires:

 

 

-

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

 

Day

Year

 

 

 

 

 

 

 

 

I am renewing within 60 days prior to the expiration date of my initial registration.

INITIAL STATE BOARD FOR LICENSING CONTRACTORS INFORMATION (CHECK ONE)

The business does not have a license issued by the State Board for Licensing Contractors. Please renew the Construction Services Provider registration ($100.00).

The business has a license issued by the State Board for Licensing Contractors (details below).

License #:Exp. Date:

 

 

INITIAL LOCAL BUSINESS LICENSE INFORMATION

 

County:

 

 

 

 

 

License #:

 

Exp. Date:

 

 

City/Town:

 

 

 

 

License #:

 

Exp. Date:

 

 

 

 

 

 

 

 

 

 

ATTESTATION

 

By checking this box, I attest that I am still afiliated with the business under which I originally qualiied and I still meet the ownership 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. I understand that any false statement I make on the application is subject to the penalties of per- jury set out in TCA §39-16-702.

By checking this box, I understand that I waive my right to sue under workers’ compensation law if I am injured on a job and have utilized the workers’ compensation exemption on that job.

Applicant Signature:

 

Date:

ss-4528 (1/13)

RDA 1762

Form Characteristics

Fact Name Description
Registration Requirement The applicant must register on the Workers' Compensation Exemption Registry if they meet the qualifications outlined in T.C.A. § 50-6-901 et seq.
Filing Options Forms can be submitted online, by mail, or in person. Each method has specific instructions and potential fees.
Filing Fees The fee is $100 for applicants without a contractor's license and $50 for those with an active license, payable via check or credit card depending on the submission method.
Expiration Date Registrations must be renewed within 60 days prior to the expiration date to avoid rejection of the form.
Consequences of False Statements Any false statement on the application can lead to penalties of perjury per T.C.A. § 39-16-702.

Guidelines on Utilizing Tn Workers Compensation Exemption

Before submitting the Tn Workers Compensation Exemption form, ensure all information is accurate and complete. Incomplete or incorrect forms will be rejected, necessitating a new application.

  1. Visit http://tnbear.tn.gov/wc/default.aspx to access the form.
  2. Choose your submission method: E-file, Print and Mail, Paper submission, or Walk-in.
  3. If E-filing, complete the form online, pay the filing fee by credit card or debit card, and note the convenience fee.
  4. If using Print and Mail, fill out the form online, then print it. Mail it 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.
  5. For Paper submission, obtain a blank form by email, phone, or in person. Complete the form and mail it to the Secretary of State’s office.
  6. Complete the applicant information section, including the registration control number, full legal name, date of birth, last 4 digits of Social Security Number, phone number, and email address.
  7. Provide the physical address of the business and mailing address, ensuring they meet the requirements.
  8. Indicate the expiration date of the initial registration and check the box if renewing within the required 60 days.
  9. Complete the licensing information section, checking the appropriate box based on contractor licensing status.
  10. Fill in local business license information, including county and city license details, if applicable.
  11. Check the attestation boxes confirming affiliation with the business and understanding the workers' compensation laws.
  12. Sign and date the form to finalize your application.
  13. Include the appropriate filing fee ($100.00 or $50.00, depending on licensing status) and submit the application.

What You Should Know About This Form

What is the Tn Workers Compensation Exemption Form?

The Tn Workers Compensation Exemption Form, also known as SS-4528, is a document that allows certain business owners engaged in the construction industry to register for a workers' compensation exemption in Tennessee. By obtaining this exemption, eligible applicants are exempt from carrying workers' compensation insurance. This process is governed by Tennessee code, specifically T.C.A. § 50-6-901 et seq.

Who is eligible to apply for the exemption?

To qualify for the exemption, applicants must be officers, members, partners, or sole proprietors actively engaged in the construction industry. They must meet the ownership requirements set forth in the applicable Tennessee laws. If you’re unsure about your eligibility, it’s recommended to consult the relevant legal guidelines or contact the Secretary of State’s office for assistance.

How can I submit the Workers Compensation Exemption Form?

There are several methods available for submitting the form. You can choose to e-file through the Tennessee Business Services website, print and mail it, or submit a paper application. If using e-filing, be aware that a convenience fee applies. You can also obtain a blank form by visiting the Secretary of State’s office in person or contacting them via email or phone.

What is the filing fee associated with this form?

The filing fee varies based on whether the applicant holds an active contractor's license. For those without a license, the fee is $100. For licensed contractors, the fee is $50. Payments can be made by check, cashier's check, or money order, and cash is only accepted in walk-in submissions. If the payment is not correct, your application may be rejected.

What happens if my application is incomplete or inaccurate?

Applications that are incomplete or inaccurate will be rejected. It is essential to fill out the form carefully and ensure all necessary information is provided. Double-check dates, signatures, and all required details to avoid potential delays or rejections in your exemption registration.

When should I renew my registration?

You should renew your registration within 60 days prior to the expiration date of your initial workers' compensation exemption registration. If you miss this window, you will need to submit a new Initial Workers’ Compensation Exemption Registration Application Form, which can be more cumbersome than simply renewing.

What is the attestation section for?

The attestation section requires you to confirm that you still meet all the requirements for the workers' compensation exemption and that you are still affiliated with the business your original registration was filed under. Checking the necessary boxes is crucial since failing to do so will lead to the rejection of your application. Additionally, it underscores the importance of providing truthful information under the penalties of perjury.

Common mistakes

Filling out the Tennessee Workers’ Compensation Exemption form can seem straightforward, but many people make mistakes that can lead to rejection of their application. One common mistake is failing to provide the correct registration control number. This unique number is assigned during the initial application process. Applicants often overlook its importance, leading to delays and additional paperwork.

Another frequent issue is incomplete applicant information. Fields such as the full legal name of the applicant, date of birth, and the last four digits of their Social Security Number must be filled out precisely. Some individuals may skip providing their middle initial or misformat their birthdate, resulting in a rejection. It's essential to double-check each entry for accuracy.

Many applicants forget to include a valid phone number and email address. This information is crucial for the Secretary of State’s office to contact the applicant if there are questions or updates regarding their filing. It might feel insignificant, but an absent contact method can stall the entire process.

When it comes to addresses, applicants often make the mistake of using a post office box instead of a physical address. The form clearly states that a physical address is required. The inclusion of a post office box can result in an automatic rejection, as the address must reflect the applicant’s principal business location.

Additionally, many individuals confuse the renewal time frame. Applicants must renew within 60 days of their initial registration expiration. Those who attempt to renew outside this window face rejection and are required to file a new initial application. This specific time frame is crucial for maintaining exemption status.

Lastly, forgetting to provide a signature and date on the application can lead to immediate rejection as well. This formality serves as a declaration that the applicant meets all necessary requirements and understands the implications of applying for a workers’ compensation exemption. Ensuring that every part of the form is complete and accurate is essential for a successful application.

Documents used along the form

The Tennessee Workers' Compensation Exemption form (ss-4528) is an essential document for individuals seeking to register for an exemption under the state's workers' compensation laws. Alongside this form, several other documents and forms are commonly submitted to ensure compliance with state regulations. These documents serve specific purposes and help facilitate the application process.

  • Initial Workers' Compensation Exemption Registration Application Form (ss-4523): This form is filed by individuals who are applying for workers' compensation exemption for the first time. It requires detailed information about the applicant and their business to determine eligibility according to state guidelines.
  • Workers’ Compensation Exemption Registration Voluntary Revocation Form (ss-4529): This form must be completed when an individual wishes to withdraw an existing workers' compensation exemption registration. It allows applicants to officially notify the state of their intent to cease coverage under the exemption.
  • State Board for Licensing Contractors Application: For those who operate within the construction industry, this application is necessary to obtain a contractor's license. The license ensures that the contractor meets state requirements and can legally conduct business.
  • County Business License Application: Depending on the county, a business may also need a county-specific business license. This application helps verify that the business adheres to local regulations and can operate within the jurisdiction.
  • City or Municipal Business License Application: Similar to the county license, certain cities may require applicants to obtain a municipal license. This application procedure ensures compliance with city-specific ordinances and regulations governing business operations.

Each of these documents plays a vital role in the broader application process for workers’ compensation exemptions. Understanding their significance not only aids in completing a compliance-related filing but also helps ensure that all necessary requirements are fulfilled, paving the way for the smooth operation of one’s business.

Similar forms

  • Workers’ Compensation Exemption Application Form (ss-4523): This form is used for the initial application for a workers' compensation exemption, similar to the renewal process of the ss-4528. Both require detailed personal information and attest to the applicant's eligibility under the law.

  • Workers’ Compensation Exemption Registration Voluntary Revocation Form (ss-4529): This document allows individuals to voluntarily revoke their current exemption registration. It shares similarities with the exemption renewal form in that both require the applicant to affirm their current business status and relationship.

  • Business Entity Registration Form: Like the exemption forms, this document collects essential information about the business and its leadership. Both processes demand accurate information to be registered with the Secretary of State’s office.

  • State Board for Licensing Contractors Application: This application is required for businesses aiming to operate legally within the construction scope. The focus on regulatory compliance and personal identification parallels the requirements seen in the workers' compensation exemption forms.

  • County Business License Application: A county business license is often necessary for operational legitimacy. As with the workers' compensation exemption forms, this application includes details about the business location and ownership.

  • City/Town Business License Application: Similar to the county's license application, this document requires specific information about the business's operation within city limits, drawing parallels with the detailed requirements of the exemption forms.

  • Renewal Application for Business Licenses: The renewal process for business licenses shares elements with the ss-4528, as both necessitate an updated verification of business status and affiliated ownership.

  • Tax Registration Form: This form ensures tax compliance for businesses. Both forms emphasize the importance of accurate reporting and legal compliance, reflecting the necessity of maintaining good standing with authorities.

  • Employer Identification Number (EIN) Application: The EIN application handles tax identification for businesses. This application aligns with the workers’ compensation exemption in requiring valid identification information and compliance with legal standards.

  • Business Affidavit Form: This document asserts the truthfulness of certain business claims under oath. Both the affidavit and the exemption forms contain attestation sections where the applicant must affirm the correctness of the information provided.

Dos and Don'ts

When completing the Tn Workers Compensation Exemption form, there are important practices to keep in mind. Here’s a list of what you should and shouldn’t do.

  • Do ensure you enter accurate information in all required fields, including your full name, registration control number, and dates.
  • Do check the expiration date of your initial registration and renew within the required timeframe, ideally 60 days prior to expiration.
  • Do verify that your physical address is current and does not include a post office box.
  • Do sign and date the application to avoid rejection due to incomplete submission.
  • Do confirm the filing fee is correct based on whether or not you hold a contractor’s license.
  • Don't use a complete Social Security Number as it will lead to rejection; instead, only enter the last four digits.
  • Don't forget to include both the mailing and physical addresses if they differ, clearly distinguishing between the two.
  • Don't neglect to check all necessary boxes for attestation, as failing to do so will make your application invalid.
  • Don't submit the form without the corresponding filing fee; applications lacking the fee will be rejected.
  • Don't wait until the last minute to submit your application, as processing delays can occur.

Misconceptions

Misconceptions often surround the Tennessee Workers' Compensation Exemption form. Here are seven common ones:

  • 1. Anyone can apply for an exemption. This is not true. Only officers, members, partners, or sole proprietors in the construction industry can seek an exemption. They must meet specific eligibility criteria outlined in T.C.A. § 50-6-901 et seq.
  • 2. You can submit the form without a filing fee. A filing fee is required. The amount depends on whether the applicant has a contractor's license. It is $100 for applicants without a license and $50 for those with an active license.
  • 3. There is no time limit for renewing the exemption. Applications must be renewed within 60 days before the expiration date. Failing to do this will result in rejection, necessitating the completion of a new Initial Workers’ Compensation Exemption Registration Application Form.
  • 4. You can use any address for the physical address. A valid physical address is mandatory, and a post office box is not acceptable. The physical address must represent the location of the principal business office.
  • 5. The exemption can be transferred between businesses. If an applicant is no longer affiliated with the original business, a new registration form must be submitted. The previous exemption must also be revoked.
  • 6. Signing the application is optional. It is crucial to sign and date the application. Failure to do so will result in rejection, regardless of the other information provided.
  • 7. You can file the application in any way you like. While several submission methods exist, they must adhere to specific guidelines. Options include e-filing, printing and mailing, or submitting in person. Each method has its own requirements, including payment of the filing fee.

Clearing these misconceptions can help applicants navigate the process more efficiently and avoid unnecessary rejections.

Key takeaways

Filing for a Workers’ Compensation Exemption in Tennessee can be straightforward if the following key points are kept in mind:

  • Submission Methods: You can submit the exemption form online, by mail, in-person, or through a paper application. Each method has specific instructions and associated fees, so choose the one that best suits your needs.
  • Accuracy is Crucial: Complete all sections of the application with accurate information. Incomplete or incorrect forms will be rejected, requiring resubmission.
  • Renewal Timing: Submit your renewal application within 60 days prior to the expiration date of your initial registration. If you miss this window, you will need to complete a new Initial Workers’ Compensation Exemption Registration Application.
  • Filing Fees: Be aware of the filing fees, which differ depending on whether you hold an active contractor’s license. Make sure to include the correct payment method with your application to avoid rejection.