Forms
- Claims Forms
- Adjuster Forms
- Employer Forms
- Attorney and Pro Se Claimant Forms
- Motions in Medical Fee Disputes
- Peace Officer Forms
- Surety Forms
- Rehabilitation Forms
- Records Requests
Claims Forms (top)
- First Report of Injury or Illness Form(IC-1) and First Report of Injury 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. 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)
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
Peace Officer Forms
- Employer Application for Reimbursement
- Complaint for Benefits Under Peace Officer and Detention Officer Temporary Disability Act
Surety Forms (top)
- Claims Adjuster Assignment Form
- In-State Adjuster Change Form
- Insurance Company Application
- NCCI Rates
- Out-of-State Check Writing, Application and Affidavit
- Report of Outstanding Awards (IC-36) and Instructions for IC-36
- Workers' Compensation Payment on Medical-Only Claims or Indemnity Payments (IC2-327) and Instructions for IC2-327
- Self-Insurance Application (IC-4006) and Supplemental (IC-4006sup)
- Self-Insurer's Compensation Bond
- Self-Insured Employer Report of Total Unpaid Liability (IC-211)
- Semi-Annual Premium Tax Form (IC-4008)
- Semi-Annual Premium Tax Form for Self-Insurers (IC-4010) and Computation Form (IC-4010a)
- Workers' Compensation Deductible Policy Report (IC-4008LD) and Instructions for IC-4008LD
- Contact Form
Rehabilitation Forms (top)
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. These forms may be mailed, faxed, or sent as email attachments to the Industrial Commission at the address indicated in the "Contact Us" section of the web site. Forms requiring original signatures/notary must be mailed.
- Request for Workers' Compensation Records by Parties (RMR-1)
- Employer Certificate and Request for Work History – For Employers Subject to the ADA (RMR-2)
- Employer Certificate and Claims History Release – For Employers NOT Subject to the ADA (RMR-3)
- Claimant's Request for Personal Workers' Compensation Records (RMR-4)
- Request for Records – Other than Workers' Compensation Records (RMR-5)