Form SS-4526 "Workers' Compensation Exemption Registration Applicant Correction Form" - Tennessee

What Is Form SS-4526?

This is a legal form that was released by the Tennessee Secretary of State - a government authority operating within Tennessee. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2011;
  • The latest edition provided by the Tennessee Secretary of State;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form SS-4526 by clicking the link below or browse more documents and templates provided by the Tennessee Secretary of State.

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Download Form SS-4526 "Workers' Compensation Exemption Registration Applicant Correction Form" - Tennessee

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ss-4526 (10/11)
Business Services Division
Tre Hargett, Secretary of State
State of Tennessee
INSTRUCTIONS
WORKERS’ COMPENSATION EXEMPTION REGISTRATION APPLICANT CORRECTION FORM (ss-4526)
SUBMISSION OPTIONS
Forms may be filed using one of the following methods:
Print and Mail: Go to http://TNBEAR.TN.gov/WC.Exxemption RegInstr.aspx. Use the online tool to complete
the application. Print and mail the application along with the required filing fee to the Secretary of State’s office,
th
Workers’ Compensation Exemption Registry at 6
FL – Snodgrass Tower, 312 Rosa L. Parks AVE, Nashville, TN
37243.
Paper submission: A blank application may be obtained by going to http://TNBEAR.TN.gov/WC, by e-mailing
the Secretary of State at WorkersComp.ExemptionRegistry@tn.gov, or by calling (615)741-0526. The
application is hand printed in ink or computer generated and mailed along with the requiring filing fee to the
th
Secretary of State’s office, Workers’ Compensation Exemption Registry at 6
FL – Snodgrass Tower, 312 Rosa L.
Parks AVE, Nashville, TN 37243.
Forms must be accurately completed in their entirety. Forms that are inaccurate or incomplete will be rejected.
APPLICANT INFORMATION
Registration Control Number: 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/WCFillingSearch.aspx.
The applicant should be the officer, member, partner, or sole proprietor who is engaged in the construction industry
and is currently listed on the Workers’ Compensation Exemption Registry.
First, MI, Last: Enter the full legal name of the applicant (first name, middle initial, last name).
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.
INCORRECT DATA
If you are attaching a copy of the filed document that is incorrect, check the first box.
Page 1 of 2
ss-4526 (10/11)
Business Services Division
Tre Hargett, Secretary of State
State of Tennessee
INSTRUCTIONS
WORKERS’ COMPENSATION EXEMPTION REGISTRATION APPLICANT CORRECTION FORM (ss-4526)
SUBMISSION OPTIONS
Forms may be filed using one of the following methods:
Print and Mail: Go to http://TNBEAR.TN.gov/WC.Exxemption RegInstr.aspx. Use the online tool to complete
the application. Print and mail the application along with the required filing fee to the Secretary of State’s office,
th
Workers’ Compensation Exemption Registry at 6
FL – Snodgrass Tower, 312 Rosa L. Parks AVE, Nashville, TN
37243.
Paper submission: A blank application may be obtained by going to http://TNBEAR.TN.gov/WC, by e-mailing
the Secretary of State at WorkersComp.ExemptionRegistry@tn.gov, or by calling (615)741-0526. The
application is hand printed in ink or computer generated and mailed along with the requiring filing fee to the
th
Secretary of State’s office, Workers’ Compensation Exemption Registry at 6
FL – Snodgrass Tower, 312 Rosa L.
Parks AVE, Nashville, TN 37243.
Forms must be accurately completed in their entirety. Forms that are inaccurate or incomplete will be rejected.
APPLICANT INFORMATION
Registration Control Number: 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/WCFillingSearch.aspx.
The applicant should be the officer, member, partner, or sole proprietor who is engaged in the construction industry
and is currently listed on the Workers’ Compensation Exemption Registry.
First, MI, Last: Enter the full legal name of the applicant (first name, middle initial, last name).
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.
INCORRECT DATA
If you are attaching a copy of the filed document that is incorrect, check the first box.
Page 1 of 2
ss-4526 (10/11)
If you do not have a copy of the incorrect document, check the second box. Enter the form name (For example: ss-
4523) of the incorrect document, the date it was filed, and a description of the incorrect data.
CORRECT DATA
If you are attaching the corrected document to be filed, check the box.
If you do not have the corrected document to be filed, enter the correct information in the space provided. Be sure
that the corrected information is complete, accurate, and in the proper form. If more space is needed, write “SEE
ATTACHED DOCUMENT” in this space.
ATTESTATION
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 correct a data error on the registry. Failure to sign
and date the form will result in this form being rejected.
FILING FEE
Filing fee for an applicant correction form is $20.00. 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 or debit cards are not accepted
for this filing.
submitted without the proper filing fee will be rejected.
Forms
Page 2 of 2
WORKERS’ COMPENSATION EXEMPTION REGISTRATION
APPLICANT CORRECTION FORM
(ss-4526)
For Office Use Only
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 $20.00
APPLICANT INFORMATION
:
Registration Control #
First:
MI:
Last:
Last 4 digits of SSN:
Date of Birth:
/
/
X
X
X
X
X
-
-
Month
Day
Year
INCORRECT DATA
(CHECK ONE)
 A copy of the incorrect document (as filed) is attached.
 Name of the incorrect document, filing date, and description of the incorrect data:
CORRECT DATA
 A copy of the corrected document to be filed is attached.
ATTESTATION
 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 perjury
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-4526 (10/11)
RDA 1762
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