FOR I.C. USE ONLY STATE OF IDAHO CERTIFICATE OF VERIFICATION OF WORKERS' COMPENSATION INSURANCE IC# __________________ Received _____________
1. 2. 3. 4. 5. 6. 7. 8. 9.
Contractor's Name ____________________________________________________________________ Business Name ________________________________________________________________________ Contractor's Federal Identification Number ___________________________________________ Contractor's Business Address ________________________________________________________ Street, Box # City, State Zip Contractor's Business Telephone Number _______________________________________________ Contractor's Home Address ____________________________________________________________ Street, Box # City, State Zip Name of Supervisor in charge of project ______________________________________________ Supervisor's Business Address ________________________________________________________ Street, Box # City, State Zip Supervisor's Business Telephone ______________________________________________________
10. Supervisor's Home Address ____________________________________________________________ Street, Box # City, State Zip 11. Classification of Business Corporation (a) (List names, addresses & telephone numbers of corporate officers and directors, and percent of ownership.)
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Partnership/Limited Liability Company (b) (List partner/member names, addresses, telephone numbers, and percent of ownership.)
Other - Please explain
Description of Project 12. 13. 14. 15. Contract # ______________________________________ Estimated Start Date______________ Location of Work_____________________________________________________________________ Description of Work _________________________________________________________________ Forest Service District Office Overseeing Contract __________________________________
16. DO YOU HAVE WORKERS' COMPENSATION INSURANCE?
17. Workers' Compensation Insurance Company Name of Carrier____________________________________________________________________ Policy # ____________________________________ Effective Date ______________________
Name of Agent ________________________________ Tel. # ______________________________ Address ____________________________________________________________________________ Street, Box City, State Zip Extraterritorial Coverage #_________________________________________________________ State ______________ 18. Date Approved _______________ Expiration Date _____________
If Contractor is a sole proprietorship/partnership/limited liability company, will workers other than the proprietor or partners/members be performing any of the work to be done under this contract?
a. If yes, state the approximate number of such workers and, if known, their names, permanent addresses, telephone numbers, and date of hire. (Attach additional pages, if needed.)
If Contractor is a corporation, will workers who are not officers and 10% shareholders and directors of the corporation be performing any of the work to be done under this contract?
If yes, state the approximate number of such workers and, if known, their names, permanent addresses, telephone numbers, and date of hire. (Attach additional pages, if needed.)
Do you intend to use any sub-contractors to assist you in the performance of this contract? Note: All sub-contractors used on this contract must also submit a Certificate of Verification of Workers' Compensation Insurance for approval prior to commencing work on this contract.
If yes, state their names, business names, permanent addresses and telephone numbers.
Based upon my knowledge of the work to be performed under the contract specified on page 1 and upon my knowledge of work practices, methods and technologies to be applied during this contract, I estimate that __________ workers are necessary to do the work in the time prescribed, assuming average production rates and conditions. I certify that the above information is true and correct to the best of my knowledge and belief. Further, I agree to inform the Industrial Commission Compliance Officer if there is any change in the above information during the time this contract is in effect.
_______________________________________________ Type or Print Contractor's Name By: ___________________________________________ Signature Date: _________________________________________
23. If the business is a partnership, limited liability company or corporation, this document requires the signature of all of the partners/members/corporate officers. (Attach additional pages if necessary.) Date _________________ Date _________________ Date _________________
___________________________________________________________ Partner/Member/Corp. Off. Title % of Ownership ___________________________________________________________ Partner/Member/Corp. Off. Title % of Ownership ___________________________________________________________ Partner/Member/Corp. Off. Title % of Ownership
___________________________________________________________ Date _________________ Partner/Member/Corp. Off. Title % of Ownership -----------------------------------------------------------------------------------------CONTRACTOR - DO NOT WRITE BELOW THIS LINE
Based solely upon the assertions above set forth, and without warranty of continued compliance, the Idaho Industrial Commission finds that Contractor:
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Currently carries workers' compensation insurance as required by state law. Has a current extraterritorial on file from the State of ______________ which covers only _________________ based employees while working temporarily in the State of Idaho. Extraterritorial coverage expires __________________.
Is not required to provide workers' compensation insurance because:
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Is a partnership/limited liability company/sole proprietor which employs no workers other than the partners/members/sole proprietor and will not employ any other workers under this contract. Is a corporation which employs no workers other than individuals who are corporate officers, directors and 10% shareholders and will not employ any other workers under this contract. Other (Specify):
(By making the above finding, the Commission does not warrant continued compliance.)
Has not obtained the required workers' compensation insurance. ______________________________________ Industrial Commission Compliance Officer
Date___________________________________ Contract/Solicitation # ________________