Declaration Under Idaho Code printable pdf download

DECLARATION UNDER IDAHO CODE § 72-212(5)

THE VALIDITY OF THIS DECLARATION IS SUBJECT TO THE REQUIREMENTS OF IDAHO CODE § 72-212(5).

EMPLOYEE

To be completed by employee. Please type or print.

Employee Name: _______________________________________________________________________

Mailing Address: _______________________________________________________________________

Street Address or Post Office Box

City

State

Zip Code

Physical Address: _______________________________________________________________________

Street Address

City

State

Zip Code

Telephone Number: _________________________ Social Security Number: ______________________

Relationship to Employer: ________________________________________________________________

EMPLOYER

To be completed by employer. Please type or print.

Name of Sole Proprietor Employer: _______________________________________________________

Business Name, If Any: _________________________________________________________________

Federal Employer ID #: _________________________________ Telephone #: ___________________

Physical Location of Business: ____________________________________________________________

Street

City

State

Zip Code

Mailing Address of Business: _____________________________________________________________

Street or Post Office Box

City

State

Zip Code

Home Address of Employer: _____________________________________________________________

Street

City

State

Zip Code

Employer Information Provided By:_______________________________________________________

Please type or print name

If employer has a workers' compensation insurance policy, complete the following:

Insurance Company: ____________________________________________________________________

Policy #: _____________________________________ Eff. Date: ______________________________

CHECK ONE OF THE FOLLOWING:

/ /

I hereby exclude myself from coverage under the Idaho Workers' Compensation Law and understand that I am not eligible

for workers' compensation insurance benefits until this declaration is revoked.

/ /

I hereby revoke the election of exemption previously filed with the Industrial Commission.

By my signature I certify that the foregoing is true and correct, to the best of my knowledge.

Signature of Employee: _______________________________________ Date: _______________________

Signature of Employer: _______________________________________ Date: _______________________

Form IC53 - Revised 9/16/97

Declaration Under Idaho Code

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