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Workers Compensation Complaint And Industrial Special Indemnity Fund IC-1002 - Idaho
| Workers Compensation Complaint And Industrial Special Indemnity Fund Form. This is a Idaho form and can be used in Attorney Workers Compensation . |
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ORIGINAL TO: INDUSTRIAL COMMISSION, JUDICIAL DIVISION, P.O. BOX 83720, BOISE, IDAHO 83720-0041 WORKERS COMPENSATION COMPLAINT AGAINST THE INDUSTRIAL SPECIAL INDEMNITY FUND (ISIF) CLAIMANTS NAME AND ADDRESS CLAIMANTS ATTORNEYS NAME AND ADDRESS EMPLOYERS NAME AND ADDRESS EMPLOYERS ATTORNEYS NAME AND ADDRESS I.C. NUMBER OF CURRENT CLAIM WORKERS COMPENSATION INSURANCE CARRIERS (NOT ADJUSTERS) NAME AND ADDRESS DATE OF INJURY NATURE AND CAUSE OF PHYSICAL IMPAIRMENT PR E-EXISTING CURRENT INJURY OR OCCUPATIONAL DISEASE STATE WHY YOU BELIEVE THAT THE CLAIMANT IS TOTALLY AND PERMANENTLY DISABLED: DATE SIGNATURE OF PARTY OR ATTORNEY CERTIFICATE OF SERVICE 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 v ia: personal service of process Dept. of Administration Boise, Idaho 83720-7901 regular U.S. Mail via: personal service of process Claimants Name regular U.S. Mail Address via: personal service of process Employers Name regular U.S. Mail Address via: personal service of process Suretys Name regular U.S. Mail Address I have not served a copy of the Complaint upon anyone. NOTICE: Pursuant 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 prio r to the filing of a complaint against ISIF. 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. IC1002 (REV. 1/01/2004) COMPLAINT AGAINST ISIF Appendix 2
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