Idaho

State of Idaho
Industrial Commission

Forms

• Claims Forms
• Adjuster Forms
• Employer Forms
• Attorney and Pro Se Claimant Forms
• Motions in Medical Fee Disputes
• Surety Forms
• Rehabilitation Forms
• Records Requests

Claims Forms (top)

• First Report of Injury or Illness (IC-1) and Instructions
• Reimbursement for Health Care Travel Expenses (IC-432(1))
• Mediation Request Form

Adjuster Forms (top)

• Summary of Payments in Non-Fatal Cases (IC-6)
• Summary of Payments in Fatal Cases (IC-6F)
• Notice of Change Status (IC-8)

Employer Forms (top)

• Employer's Supplemental Report (IC-14)
• Election of Coverage (IC-52)
• Declaration of Exemption (IC-53) and Instructions NOTE: Applies to family members of sole proprietorship ONLY.
• Certificate of Verification Form and Instructions for US Forest Service contractors (see "Who Must Complete This Form" in the Instructions)

Attorney and Pro Se Claimant Forms (top)

• Mediation Request Form
• Workers' Compensation Complaint (IC-1001)
• Notice of Intent to File Complaint Against Industrial Special Indemnity Fund
• Complaint Against Industrial Special Indemnity Fund (IC-1002)  
• Answer to Workers' Compensation Complaint (IC-1003)  
• Subpoena (IC-1007)
• Report of Litigation Expenses, Claimant's Attorney (IC-1022)  
• Report of Litigation Expenses, Employer/Insurer Attorney (IC-1023)  
• Change of Physician, Claimant Request Form  
• Change of Physician, Employer/Insurer Response Form  
• Attorney Disclosure Statement

Motions in Medical Fee Disputes (top)

• Motion for Approval of Disputed Charge
• Response to Motion for Approval of Disputed Charge
• Motion to Present Additional Evidence
• Motion for Reconsideration

Surety Forms (top)

• Out-of-State Check Writing, Application and Affidavit in Adobe Acrobat
• Report of Outstanding Awards (IC-36)
  
• Workers' Compensation Payment on Medical-Only Claims or Indemnity Payments (IC2-327)
  
• Self-Insurance Application (IC-4006) and Supplemental (IC-4006sup)
  
• Self-Insurer's Compensation Bond
• Semi-Annual Premium Tax Form (IC-4008)
  
• Semi-Annual Premium Tax Form for Self-Insurers (IC-4010) and Computation Form (IC-4010a)
• Contact Form

Rehabilitation Forms (top)

• Rehabilitation Referral

Records Requests (top)

The Idaho Public Records Law (Idaho Code Sections 9-337 through 9-350) grants every person the right to examine and take a copy of the public records of the Idaho Industrial Commission. However, Idaho Code Section 9-340B exempts workers’ compensation records from disclosure, except in certain circumstances. Records Management Request (RMR) forms are used to request information which may be disclosed, and are available for downloading from the web site. The RMR forms are explained below. Our complete public records policy is available on line.

• Request for Workers' Compensation Records (RMR-1)
• Employer Certificate and Request for Work History (RMR-2)
• Employer Certificate and Claims History Release (RMR-3)
• Claimant's Request for Personal Workers' Compensation Records (RMR-4)