Workers' Compensation Claims Involving Medical Payments Only And Claims Involving Indemnity Payments Report

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Idaho 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. T
____________
IC-327 (rev.
/1 )
If you have any questions, please contact one of the following Financial Specialists. If your company name begins with
A through I, please contact Therese Ryan at (208) 334-6095. If your company name begins with J through Z, please
contact Shelly Tudela at (208) 334-6026.

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