Appendix 4B - Answer to Officer'sComplaint for Continuation of Salary Benefit under Peace Officer & Detention Officer Temporary Disability Act

SEND ORIGINAL TO: INDUSTRIAL COMMISSION, JUDICIAL DIVISION, P.O. BOX 83720, BOISE, IDAHO 83720-0041 ANSWER TO OFFICER’S COMPLAINT FOR CONTINUATION OF SALARY BENEFIT UNDER PEACE OFFICER & DETENTION OFFICER TEMPORARY DISABILITY ACT (Idaho Code § 72-1101, et seq.)

I.C. NO._______________________________ INJURY DATE_____________________________

The employer or employer/surety named below responds to the Officer’s Complaint by stating: COMPLAINING OFFICER’S NAME AND ADDRESS OFFICER’S ATTORNEY'S NAME AND ADDRESS EMPLOYER'S NAME AND ADDRESS TELEPHONE NUMBER: WORKERS' COMPENSATION INSURANCE CARRIER'S (NOT ADJUSTOR'S) NAME AND ADDRESS ATTORNEY REPRESENTING EMPLOYER OR EMPLOYER/SURETY (NAME AND ADDRESS) IT IS: (Check One) Admitted Denied 1. That the Complaining Officer qualifies as a peace officer or detention officer as defined under Idaho Code § 72-1101 et seq. 2. That the Officer qualifies for workers’ compensation wage loss benefits for this injury under title 72, Idaho Code . 3. That the Officer’s injury was incurred in the performance of his or her duties as an Officer . 4. That the Officer’s injury was incurred when responding to an emergency . 5. That the Officer’s injury was incurred in the pursuit of an actual or suspected violator of the law. 6. That the Officer’s injury was caused by the actions of another person after July 1, 2012 and before July 1, 2015. 7. That the Officer is temporarily incapacitated from performing his or her duties as an Officer. 8. That the average weekly wage claimed by the Officer is correct. If denied, state the average weekly wage pursuant to Idaho Code § 72-419: $__________________________. IC1003A (Rev. May 8, 2013) (COMPLETE OTHER SIDE) Answer—Page 1 of 2 – Appendix 4B

(Continued from front) 9. State with specificity what matters are in dispute and your reason for denying liability, together with any affirmative defenses. Under the Commission rules, you have 21 days from the date of service of the Complaint to answer the Complaint. A copy of your Answer must be mailed to the Commission and a copy must be served on all parties or their attorneys by regular U.S. mail or by personal service of process. Unless you deny liability, you should pay immediately the compensation required by law, and not cause the claimant, as well as yourself, the expense of a hearing. All compensation which is concededly due and accrued should be paid. Payments due should not be withheld because a Complaint has been filed. Rule 3.D., Judicial Rules of Practice and Procedure under the Idaho Workers' Compensation Law, applies. Dated Signature of Defendant or Attorney PLEASE COMPLETE CERTIFICATE OF SERVICE I hereby certify that on the _____ day of _______________, 20___, I caused to be served a true and correct copy of the foregoing Answer upon: OFFICER’S NAME AND ADDRESS EMPLOYER AND SURETY'S NAME AND ADDRESS _________________________________________ ____________________________________________ __________________________________________ _________________________________________ ____________________________________________ __________________________________________ _________________________________________ ____________________________________________ __________________________________________ via:  personal service of process via:  personal service of process  regular U.S. Mail  regular U.S. Mail ________________________________________________________________ Signature ________________________________________________________________ Type or Print Name Answer Page 2 of 2 – Appendix 4B DO YOU BELIEVE THIS CLAIM PRESENTS A NEW QUESTION OF LAW OR A COMPLICATED SET OF FACTS? IF SO, PLEASE STATE. Amount of Wage Loss Benefits Paid to Date for this injury