Fill and Sign the Box 83720 Boise Idaho 83720 0041 Form

ORIGINAL 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 I.C. NUMBER OF CURRENT CLAIM WORKERS' COMPENSATION INSURANCE CARRIER'S (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: Pur suant 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