Workers Compensation Complaint
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3SEND ORIGINAL TO: INDUSTRIAL COMMISSION, JUDICIAL DIVISION, P.O. BOX 83720, BOISE, IDAHO 83720-0041
WORKERS' COMPENSATION
COMPLAINT
CLAIMANT'S (INJURED WORKER’S) NAME AND ADDRESS
CLAIMANT'S ATTORNEY'S NAME, ADDRESS, AND TELEPHONE NUMBER
TELEPHONE NUMBER
at time of injury
WORKERS' COMPENSATION INSURANCE CARRIER'S
EMPLOYER'S NAME AND ADDRESS (
)
(NOT ADJUSTOR'S) NAME AND ADDRESS
CLAIMANT'S SOCIAL SECURITY NO.
CLAIMANT'S BIRTHDATE
DATE OF INJURY OR MANIFESTATION OF OCCUPATIONAL DISEASE
STATE AND COUNTY IN WHICH INJURY OCCURRED
WHEN INJURED, CLAIMANT WAS EARNING AN AVERAGE WEEKLY WAGE
OF: $_______________, PURSUANT TO IDAHO CODE § 72-419
DESCRIBE HOW INJURY OR OCCUPATIONAL DISEASE OCCURRED (WHAT HAPPENED)
NATURE OF MEDICAL PROBLEMS ALLEGED AS A RESULT OF ACCIDENT OR OCCUPATIONAL DISEASE
WHAT WORKERS' COMPENSATION BENEFITS ARE YOU CLAIMING AT THIS TIME?
DATE ON WHICH NOTICE OF INJURY WAS GIVEN TO EMPLOYER
TO WHOM NOTICE WAS GIVEN
HOW NOTICE WAS GIVEN
ORAL
WRITTEN
OTHER, PLEASE SPECIFY
ISSUE OR ISSUES INVOLVED
DO YOU BELIEVE THIS CLAIM PRESENTS A NEW QUESTION OF LAW OR A COMPLICATED SET OF FACTS?
YES
NO IF SO, PLEASE STATE WHY.
NOTICE: COMPLAINTS AGAINST THE INDUSTRIAL SPECIAL INDEMNITY FUND MUST BE IN ACCORDANCE
WITH IDAHO CODE § 72-334 AND FILED ON FORM I.C. 1002
(COMPLETE OTHER SIDE)
Complaint – Page 1 of 3
IC1001
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