State Of Idaho Certificate Of Verification Of Workers' Compensation Insurance
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1
2
3FOR I.C. USE ONLY
STATE OF IDAHO
CERTIFICATE OF VERIFICATION
IC# __________________
OF WORKERS' COMPENSATION INSURANCE
Received _____________
Date:
___________________
1.
Contractor's Name ____________________________________________________________________
2.
Business Name ________________________________________________________________________
3.
Contractor's Federal Identification Number ___________________________________________
4.
Contractor's Business Address ________________________________________________________
Street, Box #
City, State
Zip
5.
Contractor's Business Telephone Number _______________________________________________
6.
Contractor's Home Address ____________________________________________________________
Street, Box #
City, State
Zip
7.
Name of Supervisor in charge of project ______________________________________________
8.
Supervisor's Business Address ________________________________________________________
Street, Box #
City, State
Zip
9.
Supervisor's Business Telephone ______________________________________________________
10. Supervisor's Home Address ____________________________________________________________
Street, Box #
City, State
Zip
11. Classification of Business
/
(a)
Corporation
(List names, addresses & telephone numbers of corporate officers and directors, and
percent of ownership.)
/
(b)
Partnership/Limited Liability Company
(List partner/member names, addresses, telephone numbers, and percent of ownership.)
/
(c)
Sole Proprietorship
/
(d)
Other - Please explain
Description of Project
12.
Contract # ______________________________________ Estimated Start Date______________
13.
Location of Work_____________________________________________________________________
14.
Description of Work _________________________________________________________________
15.
Forest Service District Office Overseeing Contract __________________________________
/
/
16. DO YOU HAVE WORKERS' COMPENSATION INSURANCE?
Yes
No
1.
11/27/96
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