Idaho > Workers Compensation > Record Request
Claimants Request For Personal Workers Compensation Records RMR-4 - Idaho
| Claimants Request For Personal Workers Compensation Records Form. This is a Idaho form and can be used in Record Request Workers Compensation . |
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CLAIMANT'S REQUEST FOR PERSONAL WORKERS' COMPENSATION RECORDS In accordance with the provisions of Idaho Code ยง 9-342, the undersigned requests a copy of their own workers' compensation claims from the records of the Idaho Industrial Commission, as described below. Requester agrees to pay all billable costs incurred in responding to this request under the Idaho Public Records Law. Requester's Full Name:* Other Names Used: Social Security Number:* Date(s) of Injury:* I.C. Claim Number: Mailing Address:* Phone #/Email:* Records Requested:* ____________________________ ____________________________ __ __ __-__ __-__ __ __ __ ____________________________ ___ ___-___ ___ ___ ___ ___ ___ ____________________________ ____________________________ (____) _______________/_____ I.C. RESPONSE/NOTE AREA: Claims History Search, including IC claim status for: The past 5 years. The past ____ year period (not to exceed 30 yr). Hardcopy of Electronic First Report of Injury of: The above noted claim. All claims in requested claims history search. (Note: Information may not be available for the following for claims closed more than 10 years ago.) Hardcopy of claim file contents of: The above noted claim. All claims in requested Claims History Search. A copy of other workers' compensation records (Specify): Rehabilitation records Adjudication records (closed files only) Other records (Describe): _______________________________________ ________________________________________________________________________. The undersigned requests that this information be provided directly to: (Name) ____________________________________________ at: (Address) __________________________________________________________ __________________________________________________________________, acting as agent for requester. Requesting Individual's Signature:* ___________________________________________ Date Signed:* ________________________ (* = Completion mandatory) SEND COMPLETED REQUEST TO: IDAHO INDUSTRIAL COMMISSION, ATTN: RECORDS MANAGEMENT, PO BOX 83720, BOISE, ID 83720-0041 Revised: April 7, 2011 American LegalNet, Inc. www.FormsWorkFlow.com I.C. Records Form RMR-4
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