Find a Form

Adjuster Forms

• Notice of Change Status (IC-8)
• Notice Of Change of Status – Scheduled IME
• Affidavit of Due Diligence Form

Attorney and Pro Se Claimant Forms

• 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)
• Change of Physician, Claimant Request Form
• Change of Physician, Employer/Insurer Response Form
• Attorney Disclosure Statement
• IC Form 1022 (only complete at the Commission’s request)
• IC Form 1023 (only complete at the Commission’s request)

Claims Forms

• First Report of Injury or Illness Form (IC-1) & First Report of Injury Instructions
• Reimbursement for Health Care Travel Expenses IC-432(1)
• Mediation Request Form

Carrier Forms and Reports

• Idaho Claims Administrator Adjustment Form
• Out-of-State Check Writing, Application and Affidavit
• Report of Outstanding Awards (IC-36) & Instructions for IC-36 (Updated October 2023)
• Workers’ Compensation Payment on Medical-Only Claims and Indemnity Payments (IC2-327) & Instructions for IC2-327
• Semi-Annual Premium Tax Form (IC-4008)
• Workers’ Compensation Deductible Policy Report (IC-4008LD) and Instructions for IC-4008LD
• Change in Reporting Standards for 4008LD – Workers’ Compensation on Deductible Policy Reports – Letter from the Idaho Industrial Commission to All Insurance Companies
• Contact Form
• Continuous Bond Form – Surety Bond for Insurance Carriers

Peace and Detention Officer Disability Forms

• Application for Reimbursement
• Application for Reimbursement Documentation Standards
• Application for Appeal of Decision
• Wage Workbook for TDF Application for Reimbursement
• Officer’s Complaint for Continuation of Salary Benefit Under Peace Officer and Detention Officer Temporary Disability Act

Motions in Medical Fee Disputes

• Motion for Approval of Disputed Charge
• Response to Motion for Approval of Disputed Charge
• Motion to Present Additional Evidence
• Motion for Reconsideration

Rehabilitation Forms

• Rehabilitation Referral

Employer Coverage Forms

• Employer’s Supplemental Report (IC-14)
• Election of Coverage (IC-52)
• Employer Compliance Questionnaire
• Declaration of Exemption (IC-53) & 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)
• Application for Waiver of In-State Check Writing Requirement
• 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. Sample – Notice of Insurance Poster

Self-Insured Employers Forms and Reports

• Claims Administrator Assignment Form
• Out-of-State Check Writing, Application and Affidavit
• Workers’ Compensation Payment on Medical-Only Claims and Indemnity Payments (IC2-327) & Instructions for IC2-327
• Self-Insurance Application Supplemental (IC-4006sup)
• Self-Insurer’s Compensation Bond
• Self-Insured Employer Report of Total Unpaid Liability (IC-211)
• Semi-Annual Premium Tax Form for Self-Insurers (IC-4010) and Computation Form (IC-4010a)
• Contact Form
• Self-Insured Indemnity and Guaranty Agreement
• Self-Insured Consent of the Board of Directors
• NCCI Rates 2024 (Effective 01/01/2024 – 12/31/2024)