NOTICE OF INTENT TO FILE A WORKERS' COMPENSATION COMPLAINT AGAINST THE INDUSTRIAL SPECIAL INDEMNITY FUND
Claimant's Name and Address Employer's Name and Address
Claimant's Attorney's Name and Address
Employer's Attorney's Name and Address
Claimant's Social Security Number Claimant's Date of Birth IC Number of Current Claim Date of the Most Recent Injury
Surety's Name and Address (Not Adjuster's)
Claimant's Occupation Claimant's Weekly Wage
Nature and cause of pre-existing impairment or condition. Submit documentation.
What factors render the Claimant totally and permanently disabled? Submit documentation.
What impairment ratings has the Claimant received and from whom? Submit documentation.
Certificate of Service
I certify that on Notice of Intent upon:
Industrial Special Indemnity Fund Department of Administration P.O. Box 83720 Boise, ID 83720-7901
, I served a true and correct copy of the
Claimant's Name and Address
Employer's Name and Address
Surety's Name and Address
Medical Release I hereby authorize any defendant and defendants' legal counsel, at their sole expense to examine, inspect, receive or take copies of any medical reports, records, x-rays, or test results of hospitals, physicians or any other person, or to receive information from any person having examined me and their diagnosis, relative to my past, present, and future physical and mental condition. I also authorize and direct that a duplicate set of all documents or written records provided to said law firm, or any individual member thereof, also be provided to me or my attorney, . The defendant requesting my records shall bear the expense incurred in production of such duplicate set. I further authorize that copies of this authorization may be used in lieu of the original. THIS AUTHORIZATION IS VALID ONLY FOR THE DURATION OF THE PENDING LITIGATION. It is further understood that all information obtained under this authorization shall be regarded as confidential and maintained as such. Dated Claimant's signature
This form is to notify the Industrial Special Indemnity Fund that you intend to file a formal Workers' Compensation Complaint Against the ISIF after a period of 60 days. This time period allows the ISIF to adjudicate the claim on a more informal basis and to avoid or limit necessary litigation costs. If you wish to file a Complaint Against the ISIF after 60 days, you may do so by the standard service process. You do not need to file a copy of this form with the Industrial Commission.