Official Government Website
Adjuster Forms
- Notice of Change Status (IC-8)
- Notice Of Change of Status – Scheduled IME
- Affidavit of Due Diligence Form
Attorney and Pro Se Claimant Forms
- 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)
- Change of Physician, Claimant Request Form
- Change of Physician, Employer/Insurer Response Form
- Attorney Disclosure Statement
- IC Form 1022 (only complete at the Commission’s request)
- IC Form 1023 (only complete at the Commission’s request)
Claims Forms
- First Report of Injury or Illness Form (IC-1) & First Report of Injury Instructions
- Reimbursement for Health Care Travel Expenses IC-432(1)
- Mediation Request Form
Carrier Forms and Reports
- Idaho Claims Administrator Adjustment Form
- Out-of-State Check Writing, Application and Affidavit
- Report of Outstanding Awards (IC-36) & Instructions for IC-36
- Workers’ Compensation Payment on Medical-Only Claims and Indemnity Payments (IC2-327) & Instructions for IC2-327 (Updated December 2024)
- Semi-Annual Premium Tax Form (IC-4008)
- Workers’ Compensation Deductible Policy Report (IC-4008LD) and Instructions for IC-4008LD (Updated December 2024)
- Change in Reporting Standards for 4008LD – Workers’ Compensation on Deductible Policy Reports – Letter from the Idaho Industrial Commission to All Insurance Companies
- Contact Form
- Continuous Bond Form – Surety Bond for Insurance Carriers
Peace and Detention Officer Disability Forms
- Application for Reimbursement
- Application for Reimbursement Documentation Standards
- Application for Appeal of Decision
- Wage Workbook for TDF Application for Reimbursement
- Officer’s Complaint for Continuation of Salary Benefit Under Peace Officer and Detention Officer Temporary Disability Act
Motions in Medical Fee Disputes
- Motion for Approval of Disputed Charge
- Response to Motion for Approval of Disputed Charge
- Motion to Present Additional Evidence
- Motion for Reconsideration
Rehabilitation Forms
Employer Coverage Forms
- Employer’s Supplemental Report (IC-14)
- Election of Coverage (IC-52)
- Employer Compliance Questionnaire
- Declaration of Exemption (IC-53) & Instructions. NOTE: Applies to family members of sole proprietorship ONLY. View the chart which identifies the family relationships eligible for filing an IC53.
- Certificate of Verification Form and Instructions for US Forest Service contractors (see “Who Must Complete This Form” in the Instructions)
- Application for Waiver of In-State Check Writing Requirement
- Notice of Insurance Poster – Idaho Code § 72-312 requires employers to post notice of insurance coverage in a conspicuous place in all of their places of business. This is an example poster for the Notice of Insurance required by Idaho Code § 72-312 to be conspicuously posted at their places of business. Contact your insurance adjuster to receive a poster for your business. Sample – Notice of Insurance Poster
Self-Insured Employers Forms and Reports
- Claims Administrator Assignment Form
- Out-of-State Check Writing, Application and Affidavit
- Workers’ Compensation Payment on Medical-Only Claims and Indemnity Payments (IC2-327) & Instructions for IC2-327 (Updated December 2024)
- Self-Insurance Application Supplemental (IC-4006sup)
- Self-Insurer’s Compensation Bond
- Self-Insured Employer Report of Total Unpaid Liability (IC-211)
- IC-211 Instructions (updated July 2024)
- IC-211 Report of Total Unpaid Liability (updated July 2024)
- Semi-Annual Premium Tax Form for Self-Insurers (IC-4010) and Computation Form (IC-4010a)
- Contact Form
- Self-Insured Indemnity and Guaranty Agreement
- Self-Insured Consent of the Board of Directors
- NCCI Rates 2024 (Effective 01/01/2024 – 12/31/2024)