Industrial Commission Of The State Of Idaho Application Workers' Compensation Self-Insurance
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2INDUSTRIAL COMMISSION OF THE STATE OF IDAHO
APPLICATION
WORKERS’ COMPENSATION SELF-INSURANCE
Applicant:
Parent Company:
Main Office Address:
Adjuster:
Adjuster Address:
Three-Year Payroll:
20
: $
20
: $
3-year average payroll $
20
: $
Security Deposited: $___________________________ Type: ____________________________
Wholly-Owned Subsidiaries:
NAME
FEIN #
LOCATION
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The above-named applicant, a corporation, duly existing under the laws of the State of ______________
desiring to be fully qualified to self-insure in its workers’ compensation liability pursuant to Section 72-
301, Idaho Code, and respectfully represents:
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