Form Ic-327 - Workers' Compensation Payment On Medical-Only Claims And Indemnity Payments
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1Idaho Industrial Commission
Physical mail address:
P.O. Box 83720
700 S. Clearwater Lane
Boise, Idaho 83720-0041
Boise, Idaho 83712
Workers' Compensation Claims Involving Medical Payments Only
and Claims Involving Indemnity Payments Report
Company Name and Address
FEIN:
Reporting period:
MEDICAL ONLY CLAIMS (IC-2)
(A) Total number of medical-only claims on which payments were made during the reporting period:
____________
(B) Total amount paid on medical-only claims during the reporting period:
$___________
INDEMNITY CLAIMS (IC-327)
(C) Total number of indemnity claims on which payments (including any medical payments) were made
during the reporting period:
____________
(D) Total amount of indemnity payments (not including medical payments) during the reporting period:
$___________
(E) Total amount of all indemnity claims payments (including medical payments on indemnity claims only) $___________
Certification
State of ____________________________________
County of _____________________________________
I ,________________________________, being duly sworn on oath, state that I have read the foregoing report which sets forth certain information
relating to medical and indemnity payments made during the reporting period, that I know the contents, and that I certify the report is true and correct to
the best of my knowledge.
__________________________________________________________________________
_____________________
Signature of Preparer
Print Name
Telephone
__________________________________________________________________________
_____________________
Email Address
Fax
SUBSCRIBED AND SWORN to before me on this ____________ day of ____________________, ________
The ISIF assessment billing should be sent to:
___________________________________
Name: _______________________________________
Notary Public for
Please Print
Title: _________________________________________
___________________________________
Address: _____________________________________
My commission expires:
_____________________________________________
___________________________________
City, State, Zip
Phone:
___________________________________
.
NOTE: Failure to file this form is a misdemeanor under Idaho Code §72-327. THIS REPORT IS TO BE SUBMITTED ANNUALLY
____________
IT IS TO BE RECEIVED IN THIS OFFICE NO LATER THAN MARCH 3RD OF THE SUBSEQUENT YEAR.
If you have questions, please contact one of the following Financial Specialists.
For company names that begin with:
A :
Contact Therese Ryan at (208)334-6095 or therese.ryan@iic.idaho.gov
B - M :
Contact Alan Pace at (208)334-6083 or alan.pace@iic.idaho.gov
N - Z :
Contact Shelly Tudela at (208)334-6026 or shelly.tudela@iic.idaho.gov
(IC-327, REV 11/15)
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