Free Contact Form - Idaho


File Size: 92.5 kB
Pages: 4
Date: May 28, 2009
File Format: PDF
State: Idaho
Category: Workers Compensation
Word Count: 425 Words, 2,925 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.iic.idaho.gov/forms/ic_contact.pdf

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Company Name: ___________________________________________________________ For questions please call Dianne Johnson at (208) 334-6026 Surety Code: _____
or send email to [email protected]

PREMIUM TAX PREPARER: Contact Name: Phone #: Fax #: Toll Free #: Address: City/State/Zip: Send email to: FORM 36 PREPARER: Contact Name: Phone #: Fax #: Toll Free #: Address: City/State/Zip: Send email to: IC2, IC327 REPORT PREPARERS: Contact Name: Phone #: Fax #: Toll Free #: Address: City/State/Zip: Send email to: This form completed by: Name: Phone #: Email: Date:
Page 1 of 4

ENTER ALL CHANGES/UPDATES BELOW:

Return this form to: Idaho Industrial Commission Attn: Financial Specialist Fiscal Section P.O. Box 83720 Boise, ID 83720-0041

Company Name: ___________________________________________________________ For questions please call Dianne Johnson at (208) 334-6026 Surety Code: _____
or send email to [email protected]

ISIF ASSESSMENT BILLINGS: Contact Name: Phone #: Fax #: Toll Free #: Address: City/State/Zip: Send email to: SECURITIES DEPOSITS: Contact Name: Phone #: Fax #: Toll Free #: Address: City/State/Zip: Send email to:

ENTER ALL CHANGES/UPDATES BELOW:

This form completed by: Name: Phone #: Email: Date:
Page 2 of 4

Return this form to: Idaho Industrial Commission Attn: Financial Specialist Fiscal Section P.O. Box 83720 Boise, ID 83720-0041

Company Name: _________________________________________________________ For questions please call Andrew Harold at (208) 334-6093 Surety Code: _____
or send email to [email protected]

IDAHO CLAIMS ADMINISTRATOR:

ENTER REQUIRED INFORMATION BELOW:

[Each insurance company is required to maintain a claims office in the state of Idaho or to designate a third party claims administrator with an office in the state of Idaho. If your company uses multiple third party claims administrators in Idaho, attach a list containing the insured name, policy number, effective date, and the third party claims administrator assigned to that insured.]

Claims Administrator: Contact Person: Address: City/State/Zip: Phone #: Fax #: Toll Free #: Email Address:

This form completed by: Name: Phone #: Email: Date:
Page 3 of 4

Return this form to: Idaho Industrial Commission Attn: Financial Specialist Fiscal Section P.O. Box 83720 Boise, ID 83720-0041

Company Name: _______________________________________________________ For questions please call Scott McDougall at (208) 334-6063 Surety Code: _____
or send email to [email protected]

COMPLIANCE OFFICER/CONTACT:
[Person to contact for audits and non-compliance issues]

ENTER ALL CHANGES/UPDATES BELOW:

Contact Name: Phone #: Fax #: Toll Free #: Address: City/State/Zip: Send email to:

This form completed by: Name: Phone #: Email: Date:
Page 4 of 4

Return this form to: Idaho Industrial Commission Attn: Financial Specialist Fiscal Section P.O. Box 83720 Boise, ID 83720-0041