Document Category: Forms
| Title | Excerpt | Categories | Tags | File Date | Decision Year | Decision Month | 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 | … | 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) | … | 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) | … | 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 |