EMPLOYER CERTIFICATE AND CLAIMS HISTORY RELEASE (For Employers NOT Subject to the A.D.A.) In accordance with the provisions of Idaho Code § 74-105(10)(c), the undersigned worker hereby authorizes the release of a copy of a computer claims history search of the last five (5) years of their workers' compensation claims from the records of the Idaho Industrial Commission to the employer, prospective employer or employer's agent identified below. The employer, prospective employer or agent, by their signature below, certifies that the employer is NOT subject to the provisions of the Americans with Disabilities Act (A.D.A. ­ 42 U.S.C. 12112) or other statutory limitations. The employer also agrees to pay all billable costs incurred in responding to this request under the Public Records Law. Worker's Full Name:* Other Names Used: Worker's Address:* Worker's Home Phone #: __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ (____) ____________________ Worker's Social Security Number:* __ __ __-__ __-__ __ __ __ Authorizing Individual Worker's Signature:* ____________________________________ Date Signed:* ________________________ I.C. RESPONSE/NOTE AREA: Certified By:* ______________________________________ Printed Name & Title of Certifying Agent:* ________________________________ Representative's or Agent's Phone #/Email:* (____) _________________ Mailing Address:* _____________________________________________________________________ STATE OF _____________________ County of ______________________ ) ) ss. ) SUBSCRIBED AND SWORN TO Before me this _______ day of ______________________, ________. _________________________________________ NOTARY PUBLIC for ______________________ Residing at: ______________________________ My Commission Expires: ___________________ SEND COMPLETED REQUEST TO: IDAHO INDUSTRIAL COMMISSION, ATTN: RECORDS MANAGEMENT, PO BOX 83720, BOISE, ID 83720-0041 (* = Completion mandatory I.C. Records Form RMR-3 Revised: September, 2015 American LegalNet, Inc. www.FormsWorkFlow.com