Free APPLICATION FOR WAIVER - Idaho

Idaho Industrial Commission

APPLICATION FOR WAIVER

DATE:_________________________

COMPANY NAME:_________________________________________________ 1) ___________________________________ Name of Agent/Officer 2) ______________________________________ Printed name of 3) ___________________________________City_____________________State______ZIP______ Company Home office Address 4) ___________________________________City_____________________State______ZIP______
Mailing address if different than home office

Title __________________________________

5) If Idaho Workers' Compensation Claims will be managed by a third party adjusters TPA, please provide the following information: Name of TPA ________________________________________________ Address_________________________________City____________________State_____ZIP______ Telephone number ___________________________ or 1-800_______________________________ *Note If Company has more than one 3rd party adjuster, include with the application a list of all policy holders who are not adjusted by this adjuster. The list should include the policy holder's name and the name, address and telephone number of the adjuster designated for that policy holder. 6) Include with your application an original document signed by a banking institution which has branches in the State of Idaho, that guarantees checks drawn on your out-of state bank are negotiable upon presentation at a local bank.

Idaho Industrial Commission

AFFIDAVIT IN SUPPORT OF APPLICATION FOR WAIVER

I, the undersigned __________________________________, being duly sworn attest to the following:
(Type or print name)

1) The information contained in Company's application for Waiver and in this affidavit is complete and accurate to the best of my information and belief. 2) I am an agent or officer authorized to act on behalf of _________________________ (Company) in this application for waiver. 3) Company is duly authorized to transact workers' compensation insurance in Idaho. 4) Company agrees to follow all statutes and regulations regarding workers' compensation in the State of Idaho. 5) All adjusting and decisions regarding payment of claims will be made within the State of Idaho by Idaho licensed adjusters or staff claims examiners. The Idaho based adjusters or staff claims examiners are empowered to authorize compensation checks. 6) All of Company's Idaho workers' compensation claim files will be maintained with the State of Idaho. 7) Company agrees to cooperate with the Commission and provide information and documentation as may from time to time requested in accordance with the rules and statutes regarding workers' compensation law. 8) Company agrees to cooperate in any review of this waiver. 9) Company agrees to notify the Idaho Industrial Commission of any change in third-party adjustment designations, including any TPA changes for each policy holder.

Signature:__________________________________________

Date:___________________________

Title:______________________________________________ (Type or print title)

IDAPA 17.02.03.051. REQUIREMENTS FOR MAINTAINING IDAHO WORKERS' COMPENSATION CLAIMS FILES. All sureties, self-insured employers, and licensed adjustors servicing Idaho workers' compensation claims shall comply with the following requirements: 01. Idaho Office. All sureties, self-insured employers and licensed adjusters servicing Idaho workers' compensation claims shall maintain an office within the state of Idaho. The offices shall be staffed by adequate personnel to conduct business. The surety or self-insured employer shall authorize a member of its staff or a licensed adjuster to make decisions regarding claims pursuant to Idaho Code, Section 72-305. As staffing changes occur and, at least annually, the surety, self-insured employer or licensed adjuster shall submit to the Industrial Commission the names of those authorized to make decisions regarding claims pursuant to Idaho Code, Section 72-305. Answering machines, answering services, or toll free numbers outside of the state will not suffice. 02. Claim Files. All Idaho workers' compensation claim files shall be maintained within the state of Idaho, or if maintained on an out-of-state computer, data must be entered from within the State. Hard copies of data entry shall be maintained within the State. Claim files shall include, but are not limited to: a. b. c. Notice of Injury and Claim for Benefits; Copies of bills for medical care; Copy of lost-time computations, if applicable;

d. Correspondence reflecting reasons for any delays in payments (i.e., awaiting medical reports, clarification, questionable items on bills, etc.); e. f. Employer's Supplemental Report; and Medical reports.

03. Correspondence. All original correspondence regarding Idaho workers' compensation claims shall be mailed from and maintained at in-state offices. 04. office. 05. Notice And Claim. All Notices of Injury and Claims for Benefits, occupational illnesses and fatalities shall be sent directly to the in-state adjuster, surety, or self-insured employer. The original copy of the Notice of Injury and Claim for Benefits, occupational illness and fatality shall be sent directly to the Industrial Commission. 06. Compensation. "Compensation" is used collectively and means any or all of the income benefits the medical and related benefits and medical services made under the provision of the Workers' Compensation Act. All compensation must be issued from the in-state office. 07. prohibited. a. Checks And Drafts. Checks must be signed and issued within the state of Idaho; drafts are Date Stamp. Each of the above shall be date-stamped on the day received by the claims

However, the Commission may, upon receipt of a written Application for Waiver, grant a

waiver from the provisions of Subsections 051.06 and 051.07 of this rule to permit a surety or self-insured employer to sign and issue checks outside the state of Idaho. b. An Application for Waiver must be accompanied by an affidavit signed by an officer or principal of the surety or self-insured employer, attesting to the fact that the surety or self-insured employer is prepared to comply with all statutes and rules pertaining to prompt payments of compensation. c. All waivers shall be effective from the date the Commission issues the order granting the waiver. A waiver shall remain in effect until revoked by the Industrial Commission. At least annually, staff of the Industrial Commission may review the performance of any surety or self-insured employer for which a waiver under this rule has been granted to assure that the surety or self-insured employer is complying with all statutes and rules pertaining to prompt payments of compensation. d. If at any time after the Commission has granted a waiver, the Commission receives information permitting the inference that the surety or self-insured employer has failed to provide timely benefits to any claimant, the Commission may issue an order to show cause why the Commission should not revoke the waiver; and, after affording the surety or self-insured employer an opportunity to be heard, may revoke the waiver and order the surety or self-insured employer to comply with the requirements of Subsection 051.07 of this rule. 08. Copies Of Checks. Copies of checks and/or electronically reproducible copies of the information contained on the checks must be maintained in the in-state files for Industrial Commission audit purposes. A copy of the first check, showing signature and date, shall be sent to the Industrial Commission the same day of issuance. 09. Prompt Claim Servicing. Prompt claim servicing is defined as:

a. Payment of medical bills in accordance with the provisions of IDAPA 17.02.09.031 and 032 (formerly IDAPA 17.01.03.803.A and B); b. Payment of income benefits on a weekly basis, unless otherwise approved by the Commission. 10. Audits. The Industrial Commission will perform periodic audits to ensure compliance with the above requirements. 11. Non-Compliance. Non-compliance with the above requirements may result in the revocation of the authority of an insurance company or self-insured employer to write workers' compensation insurance in the state of Idaho, or such lesser sanctions as the Industrial Commission may impose.