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Idaho Form Center


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(IC-IA-1) First Report of Injury or Illness - 2/98
First Report of Illness or Injury Instructions in English and Spanish - N/D
(ic6) Summary of Payments in Non-Fatal Cases - 7/97
(ic6f) Summary of Payments in Fatal Cases - N/D
(ic8) Notice of Claim Status - N/D
(ic14) Employer's Supplemental Report - N/D
(ic36) Report Of Outstanding Awards For Fatal, Permanent Partial Impairment, And Permanent Total Disability Claims - N/D
Instructions for form IC-36 Report Of Outstanding Awards For Fatal, Permanent Partial Impairment, And Permanent Total Disability Claims b- N/D
(ic53) Declaration of Exemption - 9/97
Instructions for form IC-53 - N/D
(ic52) Notice of Change Status - N/D
Instructions for Election of Coverage - N/D
(ic327) Workers' Compensation Claims Involving Medical Payments Only And Claims Involving Indemnity Payments Report - 4/08
(ic432) Reimbursement for Health Care Travel Expenses - N/D
(ic1001) Workers' Compensation Complaint - 3/08
(ic1002) Complaint Against Industrial Special Indemnity Fund - 3/08
(ic1003) Answer To Complaint - 3/08
(ic1007) Subpoena - 3/95
(ic1022) Report Of Litigation Expenses (Claimant's Attorney) - N/D
(ic1023) Report of Litigation Expenses (Employer/Insurer Attorney) - N/D
(ic4006) Self-Insurance Application - N/D
(ic4006sup) Supplemental to Self-Insurance Application - N/D
(ic4008) Semi-Annual Report Workers' Compensation Premium Tax - 5/97
(ic4010) Semi-Annual Report Workers' Compensation Tax Report For Self-Insured Employers - 5/97
(ic4010a) Self-Insured Employer Semi-Annual Premium Tax Computation - 5/97
(ic9030) Rehabilitation Division Referral Form - 2/99
(isifintent) Notice of Intent to File Complaint Against Industrial Special Indemnity Fund - N/D
(disclosure) Attorney Disclosure Statement - N/D
(medreq) Mediation Request Form - N/D
(copwork) Change of Physician, Claimant Request - 3/08
(copemp) Change of Physician, Employer/Insurer Response - 3/08
(cv) Certificate of Verification Form - 11/96
Instructions for Certificate of Verification Form - 11/96
(motion-dispute) Motion For Approval Of Disputed Charge - N/D
(resp-motion-dispute) Reponse To Motion For Approval Of Disputed Charge - N/D
(reconsideration) Motion For Reconsideration - N/D
(additl-evid) Motion to Present Additional Evidence - N/D
(app-for-waiver) Application for Waiver - N/D
(contact-form) Contact Form - N/D