Contact Form

Company Name:Surety Code: PREMIUM TAX PREPARER: ENTER ALL CHANGES/UPDATES BELOW: Contact Name:Phone #:Fax #:Toll Free #:Address:City/State/Zip:Send Email to: FORM 36 PREPARER: Contact Name: Phone #: Fax #: Toll Free #: Address: City/State/Zip: Send Email to: IC2, IC327, REPORT PREPARERS: Contact Name:Phone #:Fax #:Toll Free #:Address:City/State/Zip:Send Email to: This form completed by: Return this form to: Name:Idaho Industrial CommissionPhone #:Attn: Financial Specialist Email:Fiscal SectionDate:PO Box 83720Boise, ID 83720-0041 Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Company Name:Surety Code: ISIF ASSESSMENT BILLINGS: ENTER ALL CHANGES/UPDATES BELOW: Contact Name:Phone #:Fax #:Toll Free #:Address:City/State/Zip:Send Email to: SECURITIES DEPOSITS: Contact Name:Phone #:Fax #:Toll Free #:Address:City/State/Zip:Send Email to: This form completed by: Return this form to: Name:Idaho Industrial CommissionPhone #:Attn: Financial Specialist Email:Fiscal SectionDate:PO Box 83720Boise, ID 83720-0041 Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Company Name:Surety Code:For questions please call Dale Varing at (208) 334-6029 or send email to suretyrequest@iic.idaho.gov IDAHO CLAIMS ADMINISTRATOR: ENTER REQUIRED INFORMATION BELOW: Claims Administrator:Contact Person:Address:City/State/Zip:Phone#: Fax #:Toll Free #:Email Address: This form completed by: Return this form to: Name:Idaho Industrial CommissionPhone #:Attn: Financial Specialist Email:Fiscal SectionDate:PO Box 83720Boise, ID 83720-0041 [Each insurance company is required to maintain a claims office in the state of Idaho or to designate a third party claims administrator with an office in the state of Idaho. If your company uses multiple third party claims administrators in Idaho, attach a list containingthe insured name, policy number, effective date, and the third party claims administratorassigned to that insured.] Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Company Name:Surety Code: For questions please call Scott McDougall at (208) 334-6063 or send email to scott.mcdougall@iic.idaho.gov COMPLIANCE OFFICER/CONTACT: ENTER ALL CHANGES/UPDATES BELOW: Contact Name:Phone#: Fax #:Toll Free #:Address:City/State/Zip:Send email to: This form completed by: Return this form to: Name:Idaho Industrial CommissionPhone #:Attn: Financial Specialist Email:Fiscal SectionDate:PO Box 83720Boise, ID 83720-0041[Person to contact for audits and non-compliance issues]Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com