Answer To Complaint
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2SEND ORIGINAL TO: INDUSTRIAL COMMISSION, JUDICIAL DIVISION, P.O. BOX 83720, BOISE, IDAHO 83720-0041
ANSWER TO COMPLAINT
I.C. NO._______________________________
INJURY DATE
_____________________________
-named employer or employer/surety responds to Claimant's Complaint by stating:
CLAIMANT'S NAME AND ADDRESS
CLAIMANT'S ATTORNEY'S NAME AND ADDRESS
EMPLOYER'S NAME AND ADDRESS
WORKERS' COMPENSATION INSURANCE CARRIER'S
(NOT ADJUSTOR'S) NAME AND ADDRESS
TELEPHONE NUMBER
ATTORNEY REPRESENTING EMPLOYER OR EMPLOYER/SURETY (NAME AND
ATTORNEY REPRESENTING INDUSTRIAL SPECIAL INDEMNITY FUND (NAME
ADDRESS)
AND ADDRESS)
IT IS: (Check One)
Admitted
Denied
1. That the accident or occupational exposure alleged in the Complaint actually occurred on or about
the time claimed.
2. That the employer/employee relationship existed.
3. That the parties were subject to the provisions of the Idaho Workers' Compensation Act.
4. That the condition for which benefits are claimed was caused partly
entirely
by an accident arising out of and in the course of Claimant's employment.
5. That, if an occupational disease is alleged, manifestation of such disease is or was due to the nature
of the employment in which the hazards of such disease actually exist, are characteristic of and
peculiar to the trade, occupation, process, or employment.
6. That notice of the accident causing the injury, or notice of the occupational disease, was given to the
employer as soon as practical, but not later than 60 days after such accident or 60 days of the
manifestation of such occupational disease.
7. That the rate of wages claimed is correct. If denied, state the average weekly wage pursuant to
Idaho Code, § 72-419: $________________________________________.
8. That the alleged employer was insured or approved as self-insured under the Idaho Workers'
Compensation Act.
9. What benefits, if any, do you concede are due Claimant?
(COMPLETE OTHER SIDE)
Answer—Page 1 of 2
IC1003
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