Complaint Against The Industrial Special Indemnity Fund
Download a blank fillable Complaint Against The Industrial Special Indemnity Fund in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Complaint Against The Industrial Special Indemnity Fund with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1ORIGINAL TO: INDUSTRIAL COMMISSION, JUDICIAL DIVISION, P.O. BOX 83720, BOISE, IDAHO 83720-0041
WORKERS' COMPENSATION
COMPLAINT AGAINST THE
INDUSTRIAL SPECIAL INDEMNITY FUND (ISIF)
CLAIMANT'S NAME AND ADDRESS
CLAIMANT'S ATTORNEY'S NAME AND ADDRESS
EMPLOYER'S NAME AND ADDRESS
EMPLOYER'S ATTORNEY'S NAME AND ADDRESS
WORKERS' COMPENSATION INSURANCE CARRIER'S
I.C. NUMBER OF CURRENT CLAIM
(NOT ADJUSTER’S) NAME AND ADDRESS
DATE OF INJURY
NATURE AND CAUSE OF PHYSICAL IMPAIRMENT PRE-EXISTING CURRENT INJURY OR OCCUPATIONAL DISEASE:
STATE WHY YOU BELIEVE THAT THE CLAIMANT IS TOTALLY AND PERMANENTLY DISABLED:
DATE
SIGNATURE OF PARTY OR ATTORNEY
: _________________________________________________________
PRINT OR TYPE NAME: _________________________________________________________
CERTIFICATE OF SERVICE
(Name)
Signature
I hereby certify that on the _____ day of _____________________, 20 _____, I caused to be served a true and correct copy of the
foregoing Complaint upon:
Manager, ISIF
PO Box 83720
via:
personal service of process
Dept. of Administration Boise, Idaho 83720-7901
regular U.S. Mail
Claimant's Name
via:
personal service of process
regular U.S. Mail
Address
Employer's Name
via:
personal service of process
regular U.S. Mail
Address
Surety's Name
via:
personal service of process
regular U.S. Mail
Address
I have not served a copy of the Complaint upon anyone.
NOTICE:
Pursuant to the provisions of Idaho Code § 72-334, a notice of claim must first be filed with the
Manager of ISIF not less than 60 days prior to the filing of a complaint against ISIF.
If a Complaint against the employer is outstanding, you must attach a copy of Form IC 1001 Workers' Compensation
Complaint, to this document.
An Answer must be filed on Form IC 1003 within 21 days of service in order to avoid default.
IC 1002 (Rev. May 8, 2013)
Page 1 of 1
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal