Free Microsoft Word - ic_2_327.DOC - Idaho

Idaho Industrial Commission P.O. Box 83720 Boise, Idaho 83720-0041 Workers' Compensation Claims Involving Medical Payments Only and Claims Involving Indemnity Payments Report Company Name and Address

Physical mail address: 700 S. Clearwater Lane Boise, Idaho 83712

FEIN:
Reporting period:

MEDICAL ONLY CLAIMS (IC-2) (A) Total number of medical-only claims on which payments were made during the reporting period: (B) Total amount paid on medical-only claims during the reporting period: INDEMNITY CLAIMS (IC-327) (C) Total number of indemnity claims on which payments (including any medical payments) were made during the reporting period: (D) Total amount of indemnity payments (not including medical payments) during the reporting period: ____________ $___________ ____________ $___________

(E) Total amount of all indemnity claims payments (including medical payments on indemnity claims only.) $___________ Certification State of ____________________________________ County of _____________________________________

I ,________________________________, being duly sworn on oath, state that I have read the foregoing report which sets forth certain information relating to medical and indemnity payments made during the reporting period, that I know the contents, and that I certify the report is true and correct to the best of my knowledge.

__________________________________________________________________________ Signature of Preparer Print Name

_____________________ Telephone

__________________________________________________________________________ Email Address

_____________________ Fax

SUBSCRIBED AND SWORN to before me on this ____________ day of ____________________, ________ The ISIF assessment billing should be sent to: Name: _______________________________________
Please Print

___________________________________ Notary Public for ___________________________________ My commission expires: ___________________________________

Title: _________________________________________ Address: _____________________________________ _____________________________________________
City, State, Zip

Phone: ____________________________________
NOTE: Failure to file this form is a misdemeanor under Idaho Code §72-327. This form is to be submitted annually with the Idaho Semi-Annual Workers' Compensation Premium Tax Report. IC-327 (rev. 06/25/2009)