Fill and Sign the Notice to File Workers Comp Complaint Form Idaho Department of Administration

NOTICE OF INTENT TO FILE A WORKERS’ COMPENSATION COMPLAINT AGAINST THE INDUSTRIAL SPECIAL INDEMNITY FUND Claimant’s Name and Address Claimant’s Attorney’s Name and Address Employer’s Name and Address Employer’s Attorney’s Name and Address Claimant’s Social Security Number Claimant’s Date of Birth IC Number of Current Claim Surety’s Name and Address (Not Adjuster’s) Claimant’s Occupation Date of the Most Recent Injury Claimant’s Weekly Wage Description of how injury occurred. Nature and cause of pre-existing impairment or condition. Submit documentation. What factors render the Claimant totally and permanently disabled? Submit documentation. What impairment ratings has the Claimant received and from whom? Submit documentation. 72-334. FILING NOTICE OF CLAIM WITH THE INDUSTRIAL SPECIAL INDEMNITY FUND -- RECORDS TO BE INCLUDED WITH NOTICE OF CLAIM “…claim shall include, but not be limited to, a detailed statement describing the disability claim and supporting documentation including relevant medical and vocational rehabilitation records.” ISIF revised form 1/25/2008 Certificate of Service I certify that on , I served a true and correct copy of the Notice of Intent upon: Industrial Special Indemnity Fund Claimant’s Name and Address Department of Administration P.O. Box 83720 Boise, ID 83720-7901 Employer’s Name and Address Surety’s Name and Address This form is to notify the Industrial Special Indemnity Fund that you intend to file a formal Workers’ Compensation Complaint Against the ISIF after a period of 60 days. This time period allows the ISIF to adjudicate the claim on a more informal basis and to avoid or limit necessary litigation costs. If you wish to file a Complaint Against the ISIF after 60 days, you may do so by the standard service process. You do not need to file a copy of this form with the Industrial Commission. Medical Release I hereby authorize any defendant and defendants’ legal counsel, at their sole expense to examine, inspect, receive or take copies of any medical reports, records, x-rays, or test results of hospitals, physicians or any other person, or to receive information from any person having examined me and their diagnosis, relative to my past, present, and future physical and mental condition. I also authorize and direct that a duplicate set of all documents or written records provided to said law firm, or any individual member thereof, also be provided to me or my attorney, . The defendant requesting my records shall bear the expense incurred in production of such duplicate set. I further authorize that copies of this authorization may be used in lieu of the original. THIS AUTHORIZATION IS VALID ONLY FOR THE DURATION OF THE PENDING LITIGATION. It is further understood that all information obtained under this authorization shall be regarded as confidential and maintained as such. Dated Claimant’s signature