Forms

Forms are available in the following categories:

(click on bold titles for additional information)

• Claims Forms
   
  • First Report of Injury or Illness (IC-1), Adobe Acrobat Version
  • First Report of Illness or Injury Instructions
  • First Report of Injury or Illness (IC-1), Microsoft Word Version
  • After You've Filled Out the First Report of Injury or Illness (Adobe Acrobat)
  • Reimbursement for Health Care Travel Expenses (IC-432(1))
  • Mediation Request Form
     
• Crime Victims Forms (including providers)
   
  • Crime Victims Application
  • Crime Victims Family Assistance Application
  • Sexual Assault Examination Reimbursement
  • Initial Treatment Plan, Medication Management
  • Initial Treatment Plan, Counseling
  • Initial Treatment Plan, Chiropractic, Massage, Other
     
• Adjuster Forms
   
  • Summary of Payments in Non-Fatal Cases (IC-6) (PDF Version)
  • Summary of Payments in Non-Fatal Cases (IC-6) (Microsoft Word Version)
  • Summary of Payments in Fatal Cases (IC-6F) (PDF Version)
  • Summary of Payments in Fatal Cases (IC-6F) (Microsoft Word Version)
  • Notice of Change Status (IC-8) (Microsoft Word) (Commission copy of the Word version may be sent as an email attachment to changeofstatus@iic.idaho.gov )
  • Notice of Change Status (IC-8) (PDF Version)
     
• Employer Forms
   
  • Employer's Supplemental Report (IC-14)
  • Election of Coverage (IC-52) and Instructions, Adobe Acrobat
  • Declaration of Exemption (IC-53) and Instructions, Adobe Acrobat NOTE: Applies to family members of sole proprietorship ONLY. See "For Employers" for details
  • Certificate of Verification Form and Instructions for US Forest Service contractors (see "Who Must Complete This Form" in the Instructions)
     
•  Attorneys and Pro Se Claimants FORMS
   
  • Mediation Request Form
  • Workers' Compensation Complaint (IC-1001) Acrobat Format 
  • Workers' Compensation Complaint (IC-1001) Word Format
  • Notice of Intent to File Complaint Against Industrial Special Indemnity Fund
  • Complaint Against Industrial Special Indemnity Fund (IC-1002) Acrobat Format
  • Complaint Against Industrial Special Indemnity Fund (IC-1002) Word Format
  • Answer to Workers' Compensation Complaint (IC-1003) Acrobat Format
  • Answer to Workers' Compensation Complaint (IC-1003) Word Format
  • Forms IC-1001, IC-1002, and IC-1003 in Word format, "Zipped" for download *
  • Forms IC-1001, IC-1002, and IC-1003 in Word format, "Self-extracting Zip" for download
  • Subpoena (IC-1007) Adobe Acrobat
  • Subpoena (IC-1007) Word Version
  • Report of Litigation Expenses, Claimant's Attorney (IC-1022) Acrobat Format
  • Report of Litigation Expenses, Employer/Insurer Attorney (IC-1023) Acrobat Format
  • Change of Physician, Claimant Request Form Acrobat Format
  • Change of Physician, Claimant Request Form Word Format
  • Change of Physician, Employer/Insurer Response Form Acrobat Format
  • Change of Physician, Employer/Insurer Response Form Word Format
  • Attorney Disclosure Statement Acrobat Format
     
• Motions IN Medical Fee Disputes
   

  • Motion for Approval of Disputed Charge (Adobe Acrobat)

  • Response to Motion for Approval of Disputed Charge (Adobe Acrobat)

  • Motion to Present Additional Evidence (Adobe Acrobat)

  • Motion for Reconsideration (Adobe Acrobat)
     

• Surety Forms
   
  • Out-of-State Check Writing, Application and Affidavit in Word 2000
  • Out-of-State Check Writing, Application and Affidavit in Adobe Acrobat
  • Report of Outstanding Awards (IC-36)
  • Instructions for the IC-36 form (Report of Outstanding Awards)
  • Workers' Compensation Payment on Medical-Only Claims or Indemnity Payments (IC2-327)
  • Self-Insurance Application (IC-4006) and Supplemental (IC-4006sup)
  • 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
   
  • Rehabilitation Referral (Injured workers may self-refer.)
  • Rehabilitation Referral (Fill-able form -- Word version. Click to open or save with MS Office templates.)
     
• Records Requests