Fill and Sign the Section 72 212idaho State Legislature Form

To be completed by employer. Please type or print.EMPLOYER Name of Sole Proprietor Employer: _______________________________________________________ Business Name, If Any: _________________________________________________________________Federal Employer ID #: _________________________________ Telephone #: ___________________Physical Location of Business: ____________________________________________________________ Street City State Zip Code Mailing Address of Business: _____________________________________________________________ Street or Post Office Box City State Zip Code Home Address of Employer: _____________________________________________________________ Street City State Zip Code Employer Information Provided By:_______________________________________________________ Please type or print name If employer has a workers' compensation insurance policy, complete the following: Insurance Company: ____________________________________________________________________ Policy #: _____________________________________ Eff. Date: ______________________________ To be completed by employee. Please type or print. EMPLOYEE Employee Name: _______________________________________________________________________Mailing Address: _______________________________________________________________________ Street Address or Post Office Box City State Zip Code Physical Address: _______________________________________________________________________ Street Address City State Zip Code Telephone Number: _________________________ Social Security Number: ______________________Relationship to Employer: ________________________________________________________________ DECLARATION UNDER IDAHO CODE § 72-212(5) THE VALIDITY OF THIS DECLARATION IS SUBJECT TO THE REQUIREMENTS OF IDAHO CODE § 72-212(5). CHECK ONE OF THE FOLLOWING: GG I hereby exclude myself from coverage under the Idaho Workers' Compensation Law and understand that I am not eligible for workers' compensation insurance benefits until this declaration is revoked. GG I hereby revoke the election of exemption previously filed with the Industrial Commission. By my signature I certify that the foregoing is true and correct, to the best of my knowledge. Signature of Employee: _______________________________________ Date: _______________________ Signature of Employer: _______________________________________ Date: _______________________ Form IC53 - Revised 9/16/97