SEND ORIGINAL TO: INDUSTRIAL COMMISSION, JUDICIAL DIVISION, P.O. BOX 83720, BOISE, IDAHO 83720-0041
ANSWER TO COMPLAINT
I.C. NO._______________________________ INJURY DATE_____________________________
The above-named employer or employer/surety responds to Claimant's Complaint by stating: The Industrial Special Indemnity Fund responds to the Complaint against the ISIF by stating:
CLAIMANT'S NAME AND ADDRESS CLAIMANT'S ATTORNEY'S NAME AND ADDRESS
EMPLOYER'S NAME AND ADDRESS
WORKERS' COMPENSATION INSURANCE CARRIER'S (NOT ADJUSTOR'S) NAME AND ADDRESS
ATTORNEY REPRESENTING EMPLOYER OR EMPLOYER/SURETY (NAME AND ADDRESS)
ATTORNEY REPRESENTING INDUSTRIAL SPECIAL INDEMNITY FUND (NAME AND ADDRESS)
IT IS: (Check One) Admitted Denied 1. That the accident or occupational exposure alleged in the Complaint actually occurred on or about the time claimed. 2. That the employer/employee relationship existed. 3. That the parties were subject to the provisions of the Idaho Workers' Compensation Act. 4. That the condition for which benefits are claimed was caused partly entirely by an accident arising out of and in the course of Claimant's employment.
5. That, if an occupational disease is alleged, manifestation of such disease is or was due to the nature of the employment in which the hazards of such disease actually exist, are characteristic of and peculiar to the trade, occupation, process, or employment. 6. That notice of the accident causing the injury, or notice of the occupational disease, was given to the employer as soon as practical but not later than 60 days after such accident or 60 days of the manifestation of such occupational disease. 7. That the rate of wages claimed is correct. If denied, state the average weekly wage pursuant to Idaho Code, § 72-419: $________________________________________. 8. That the alleged employer was insured or permissibly self-insured under the Idaho Workers' Compensation Act.
9. What benefits, if any, do you concede are due Claimant?
IC1003 (Rev. 3/01/2008)
(COMPLETE OTHER SIDE)
Answer--Page 1 of 2
(Continued from front) 10. State with specificity what matters are in dispute and your reason for denying liability, together with any affirmative defenses.
Under the Commission rules, you have 21 days from the date of service of the Complaint to answer the Complaint. A copy of your Answer must be mailed to the Commission and a copy must be served on all parties or their attorneys by regular U.S. mail or by personal service of process. Unless you deny liability, you should pay immediately the compensation required by law, and not cause the claimant, as well as yourself, the expense of a hearing. All compensation which is concededly due and accrued should be paid. Payments due should not be withheld because a Complaint has been filed. Rule 3.D., Judicial Rules of Practice and Procedure under the Idaho Workers' Compensation Law, applies. Complaints against the Industrial Special Indemnity Fund must be filed on Form I.C. 1002.
I AM INTERESTED IN MEDIATING THIS CLAIM, IF THE OTHER PARTIES AGREE. YES NO
DO YOU BELIEVE THIS CLAIM PRESENTS A NEW QUESTION OF LAW OR A COMPLICATED SET OF FACTS? IF SO, PLEASE STATE.
Amount of Compensation Paid to Date PPI/PPD TTD Medical
Signature of Defendant or Attorney ___________________________________ ___________________________________ Print or Type Name
CERTIFICATE OF SERVICE
I hereby certify that on the _____ day of _______________, 20___, I caused to be served a true and correct copy of the foregoing Answer upon: CLAIMANT'S NAME AND ADDRESS EMPLOYER AND SURETY'S NAME AND ADDRESS INDUSTRIAL SPECIAL INDEMNITY FUND (if applicable)
_________________________________________ ____________________________________________ __________________________________________ _________________________________________ ____________________________________________ __________________________________________ _________________________________________ ____________________________________________ __________________________________________ via: personal service of process regular U.S. Mail via: personal service of process regular U.S. Mail via: personal service of process regular U.S. Mail
Signature _____________________________________________________________________ Type or Print Name Answer--Page 2 of 2