Application For Waiver
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Idaho Industrial Commission
APPLICATION FOR WAIVER
Per IDAPA 17.02.03.051
DATE:_________________________
COMPANY NAME:_________________________________________________
1) ___________________________________
Title __________________________________
Name of Agent/Officer
2) ______________________________________
Printed name
3) ___________________________________City_____________________State______ZIP______
Company Home office Address
4) ___________________________________City_____________________State______ZIP______
Mailing address if different than home office
5) If Idaho Workers’ Compensation Claims will be managed by a third party adjusters TPA, please
provide the following information:
Name of TPA ________________________________________________
Address_________________________________City____________________State_____ZIP______
Telephone number ___________________________ or 1-800_______________________________
*Note If Company has more than one Idaho in-state TPA, include with the application a list of all
policy holders who are not adjusted by this adjuster. The list should include the policy holder’s name,
the complete policy number, and the name, address and telephone number of the in-state TPA designated
for that policy holder.
Revised -1-04-10
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