| Title | Summary | Categories | Tags | Link | hf:doc_categories | hf:doc_tags |
|---|---|---|---|---|---|---|
| Affidavit of Due Diligence Form | … | Forms | Adjuster Forms | forms | adjuster-forms | |
| Answer to Workers’ Compensation Complaint (IC-1003) | … | Forms | Attorney and Pro Se Claimant Forms | forms | attorney-and-pro-se-claimant-forms | |
| Application for Appeal of Decision | … | Forms, Resources | Peace & Detention Officer Disability Forms, Peace Officer & Detention Officer, Temporary Disability Claims | forms resources | peace-detention-officer-disability-forms peace-officer-detention-officer temporary-disability-claims | |
| Application for Reimbursement | … | Forms | Peace & Detention Officer Disability Forms | forms | peace-detention-officer-disability-forms | |
| Application for Reimbursement Documentation Standards | … | Forms | Peace & Detention Officer Disability Forms | forms | peace-detention-officer-disability-forms | |
| Application for Waiver of In-State Check Writing Requirement | … | Forms | Carrier Forms & Reports, Self-Insured Employers Forms & Reports | forms | carrier-forms-reports self-insured-employers-forms-reports | |
| Certificate of Verification Form | Instructions for US Forest Service contractors (see “Who Must Complete This Form” in the … | Forms | Employer Coverage Forms | forms | employer-coverage-forms | |
| Change of Physician, Claimant Request Form | … | Adjudication Division, Attorney Information, Forms | adjudication-division attorney-information forms | |||
| Change of Physician, Claimant Request Form | … | Forms, Medical Information | Attorney and Pro Se Claimant Forms, Change of Physician | forms medical-information | attorney-and-pro-se-claimant-forms change-of-physician | |
| Change of Physician, Employer/Insurer Response Form | … | Forms, Medical Information | Attorney and Pro Se Claimant Forms, Change of Physician | forms medical-information | attorney-and-pro-se-claimant-forms change-of-physician | |
| Claimant Attorney Charging Lien (PDF) | … | Adjudication Division, Attorney Information, Forms | adjudication-division attorney-information forms | |||
| Claimant Attorney Charging Lien (WORD) | … | Adjudication Division, Attorney Information, Forms | adjudication-division attorney-information forms | |||
| Claimant Attorney Disclosure Statement | … | Adjudication Division, Attorney Information, Forms | Attorney and Pro Se Claimant Forms | adjudication-division attorney-information forms | attorney-and-pro-se-claimant-forms | |
| Claimant’s Request for Personal Workers’ Compensation Records (RMR-4) | … | Forms, Injured Worker Information, Workers' Compensation | forms injured-worker-information workers-compensation | |||
| Complaint | … | Adjudication Division, Attorney Information, Forms | adjudication-division attorney-information forms | |||
| Complaint Against Industrial Special Indemnity Fund (IC-1002) | … | Adjudication Division, Attorney Information, Forms | Attorney and Pro Se Claimant Forms | adjudication-division attorney-information forms | attorney-and-pro-se-claimant-forms | |
| Computation Form (IC-4010a) | … | Forms, Insurance Information | Filing Calendar, Self-Insured Employers Forms & Reports | forms insurance-information | filing-calendar self-insured-employers-forms-reports | |
| Contact Form | Please use this form to report changes to the primary in-state claims administrator. | Forms | Carrier Forms & Reports | forms | carrier-forms-reports | |
| Continuous Bond Form – Surety Bond for Insurance Carriers | … | Forms | Carrier Forms & Reports | forms | carrier-forms-reports | |
| Current NCCI Rates for Self-Insured Employers (Effective 1/1/26 – 12/31/26) | … | Employer Information, Forms | Resources, Self-Insured Employers Forms & Reports | employer-information forms | resources self-insured-employers-forms-reports | |
| Declaration of Exemption (IC-53) | Instructions: … | Forms | Employer Coverage Forms | forms | employer-coverage-forms | |
| Election of Coverage Form (IC-52) | … | Employer Information, Forms | Employer Coverage Forms | employer-information forms | employer-coverage-forms | |
| Employer Certificate and Claims History Release – For Employers NOT Subject to the ADA (RMR-3) | … | Forms, Injured Worker Information, Workers' Compensation | forms injured-worker-information workers-compensation | |||
| Employer Certificate and Request for Work History – For Employers Subject to the ADA (RMR-2) | … | Forms, Injured Worker Information, Workers' Compensation | forms injured-worker-information workers-compensation | |||
| Employer Compliance Questionnaire | … | Forms | Employer Coverage Forms | forms | employer-coverage-forms | |
| Employer’s Supplemental Report (IC-14) | … | Forms | Claims Forms | forms | claims-forms | |
| Extraterritorial Questionnaire (EXT Form) | … | Extraterritorial Coverage & Reciprocity, Forms | extraterritorial-coverage-reciprocity forms | |||
| First Report of Injury Instructions | … | Forms, Resources | Claims, Claims Forms, Resources | forms resources | claims claims-forms resources | |
| First Report of Injury or Illness | … | Adjudication Division, Attorney Information, Employer Information, Forms, Injured Worker Information | adjudication-division attorney-information employer-information forms injured-worker-information | |||
| First Report of Injury or Illness Form (IC-1) | … | Forms | Claims Forms | forms | claims-forms | |
| First Report of Injury or Illness Instructions for Filling out Form | … | Forms, Injured Worker Information | forms injured-worker-information | |||
| Formulario para primer reporte de incidente (FROI) | … | Forms, Información en Español | forms informacion-en-espanol | |||
| Formulario para reembolso de millas | … | Forms, Información en Español | forms informacion-en-espanol | |||
| Formulario para solicitar mediación | … | Forms, Información en Español | forms informacion-en-espanol | |||
| IC Form 1022 (only complete at the Commission’s request) | … | Forms | Attorney and Pro Se Claimant Forms | forms | attorney-and-pro-se-claimant-forms | |
| IC Form 1023 (only complete at the Commission’s request) | … | Forms | Attorney and Pro Se Claimant Forms | forms | attorney-and-pro-se-claimant-forms | |
| IC-211 Instructions | … | Forms, Insurance Information | Filing Calendar, Self-Insured Employers Forms & Reports | forms insurance-information | filing-calendar self-insured-employers-forms-reports | |
| IC-211 Report of Total Unpaid Liability | … | Forms, Insurance Information | Filing Calendar, Self-Insured Employers Forms & Reports | forms insurance-information | filing-calendar self-insured-employers-forms-reports | |
| IC53 Election for Exemption form | … | Employer Information, Forms | employer-information forms | |||
| IIC New Business Information Form | … | Employer Information, Forms | employer-information forms | |||
| In-State Adjuster Change Form | … | Forms, Insurance Information | forms insurance-information | |||
| Instructions for Certificate of Verification Form | Instructions for US Forest Service contractors (see “Who Must Complete This Form” in the Instructions.) | Forms, Resources | Employer Coverage Forms | forms resources | employer-coverage-forms | |
| Instructions for IC-36 (Report of Outstanding Awards) | … | Forms, Resources | Carrier Forms & Reports | forms resources | carrier-forms-reports | |
| Instructions for IC-4008 (Semi-Annual Premium Tax Form) | … | Forms, Resources | Carrier Forms & Reports | forms resources | carrier-forms-reports | |
| Instructions for IC-4008LD | … | Forms, Insurance Information, Resources | Carrier Forms & Reports, Filing Calendar | forms insurance-information resources | carrier-forms-reports filing-calendar | |
| Instructions for IC-53 (Declaration of Exemption) | NOTE: Applies to family members of sole proprietorship ONLY. View the chart which identifies the family relationships eligible for filing an IC-53. | Forms, Resources | Employer Coverage Forms | forms resources | employer-coverage-forms | |
| Instructions for IC2-327 | … | Forms, Insurance Information | Carrier Forms & Reports, Filing Calendar, Self-Insured Employers Forms & Reports | forms insurance-information | carrier-forms-reports filing-calendar self-insured-employers-forms-reports | |
| Ledger of Benefits All Benefits Paid & Disputed | … | Adjudication Division, Attorney Information, Forms | adjudication-division attorney-information forms | |||
| Mediation Request Form | … | Forms | Attorney and Pro Se Claimant Forms, Claims Forms | forms | attorney-and-pro-se-claimant-forms claims-forms | |
| Mileage Reimbursement | … | Forms, Injured Worker Information, Insurance Information | Claims | forms injured-worker-information insurance-information | claims | |
| Motion for Approval of Disputed Charge | … | Forms | Motions in Medical Fee Disputes | forms | motions-in-medical-fee-disputes | |
| Motion for Reconsideration | … | Forms | Motions in Medical Fee Disputes | forms | motions-in-medical-fee-disputes | |
| Motion to Present Additional Evidence | … | Forms | Motions in Medical Fee Disputes | forms | motions-in-medical-fee-disputes | |
| Notice of Change of Status – Scheduled IME | … | Forms | Adjuster Forms | forms | adjuster-forms | |
| Notice of Change Status (IC-8) | … | Forms | Adjuster Forms | forms | adjuster-forms | |
| Notice of Intent to File Complaint Against Industrial Special Indemnity Fund | … | Adjudication Division, Attorney Information, Forms | Attorney and Pro Se Claimant Forms | adjudication-division attorney-information forms | attorney-and-pro-se-claimant-forms | |
| Officer’s Complaint for Continuation of Salary Benefit Under Peace Officer and Detention Officer Temporary Disability Act | … | Forms, Resources | Peace & Detention Officer Disability Forms, Peace Officer & Detention Officer, Temporary Disability Claims | forms resources | peace-detention-officer-disability-forms peace-officer-detention-officer temporary-disability-claims | |
| Rehabilitation Referral Form | … | Forms, Injured Worker Information, Resources | Rehabilitation Forms, Rehabilitation Services | forms injured-worker-information resources | rehabilitation-forms rehabilitation-services | |
| Reimbursement for Health Care Travel Expenses (IC-432(1)) | … | Forms | Claims Forms | forms | claims-forms | |
| Report of Outstanding Awards (IC-36) | Instructions for IC-36: … | Forms, Resources | Carrier Forms & Reports | forms resources | carrier-forms-reports | |
| Request for Microfilmed Workers’ Compensation Records by Parties (RMR-6) | … | Forms, Injured Worker Information, Workers' Compensation | forms injured-worker-information workers-compensation | |||
| Request for Records – Other than Workers’ Compensation Records (RMR-5) | … | Forms, Injured Worker Information, Workers' Compensation | forms injured-worker-information workers-compensation | |||
| Request for Workers’ Compensation Records by Parties (RMR-1) | … | Forms, Injured Worker Information, Workers' Compensation | forms injured-worker-information workers-compensation | |||
| Response to Motion for Approval of Disputed Charge | … | Forms | Motions in Medical Fee Disputes | forms | motions-in-medical-fee-disputes | |
| Sample – 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. | Employer Information, Forms | Employer Coverage Forms, Resources | employer-information forms | employer-coverage-forms resources | |
| Self-Insurance Application Supplemental (IC-4006sup) | … | Forms | Self-Insured Employers Forms & Reports | forms | self-insured-employers-forms-reports | |
| Self-Insured Consent of the Board of Directors | … | Forms | Self-Insured Employers Forms & Reports | forms | self-insured-employers-forms-reports | |
| Self-Insured Indemnity and Guaranty Agreement | … | Forms | Self-Insured Employers Forms & Reports | forms | self-insured-employers-forms-reports | |
| Self-Insurer’s Compensation Bond | … | Forms | Self-Insured Employers Forms & Reports | forms | self-insured-employers-forms-reports | |
| Semi-Annual Premium Tax Form (IC-4008) | … | Forms, Insurance Information | Carrier Forms & Reports, Filing Calendar | forms insurance-information | carrier-forms-reports filing-calendar | |
| Semi-Annual Premium Tax Form for Self-Insurers (IC-4010) | … | Forms, Insurance Information | Filing Calendar, Self-Insured Employers Forms & Reports | forms insurance-information | filing-calendar self-insured-employers-forms-reports | |
| Subpoena (IC-1007) | … | Forms | Attorney and Pro Se Claimant Forms | forms | attorney-and-pro-se-claimant-forms | |
| Temporary Disability Fund Reimbursement Application | … | Forms, Resources | Peace Officer & Detention Officer, Temporary Disability Claims | forms resources | peace-officer-detention-officer temporary-disability-claims | |
| Wage Workbook for TDF Application for Reimbursement | … | Forms, Resources | Peace & Detention Officer Disability Forms, Peace Officer & Detention Officer, Temporary Disability Claims | forms resources | peace-detention-officer-disability-forms peace-officer-detention-officer temporary-disability-claims | |
| Workers’ Compensation Complaint (IC-1001) | … | Forms | Attorney and Pro Se Claimant Forms | forms | attorney-and-pro-se-claimant-forms | |
| Workers’ Compensation Deductible Policy Report (IC-4008LD) | … | Forms, Insurance Information | Carrier Forms & Reports, Filing Calendar | forms insurance-information | carrier-forms-reports filing-calendar | |
| Workers’ Compensation Payment on Medical-Only Claims and Indemnity Payments (IC2-327) | … | Forms, Insurance Information, Resources | Carrier Forms & Reports, Claims, Filing Calendar, Self-Insured Employers Forms & Reports | forms insurance-information resources | carrier-forms-reports claims filing-calendar self-insured-employers-forms-reports |
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
- Employer’s Supplemental Report (IC-14)
Carrier Forms and Reports
- Application for Waiver of In-State Check Writing Requirement
- 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) and Instructions (Updated July 2025)
- 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 – Please use this form to report changes to the primary in-state claims administrator
- 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
- 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)
- 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
- Application for Waiver of In-State Check Writing Requirement
- 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 2025 (Effective 01/01/2025 – 12/31/2025)