Idaho Industrial Commission APPLICATION FOR WAIVER OF IN-STAmerican LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT IN SUPPORT OF APPLICATION FOR WAIVER I, the undersigned , being duly sworn attest to the following: (Type or print name) 1) The information contained in Company222s application for Waiver and in this affidavit is complete and accurate to the best of my information and belief. 2) I am an agent or officer authorized to act on behalf of (Company) in this application for waiver. 3) Company is duly authorized to transact workers222 compensation insurance in Idaho. 4) Company agrees to follow all statutes and regulations regarding workers222 compensation in the State of Idaho. 5) All adjusting and decisions regarding payment of claims will be made within the State of Idaho by Idaho licensed adjusters or staff claims examiners. The Idaho based adjusters or staff claims examiners are empowered to authorize compensation checks. 6) All of Company222s Idaho workers222 compensation claim files will be maintained with the State of Idaho for the period specified by Rule. 7) Company agrees to cooperate with the Commission and provide information and documentation as may from time to time be requested in accordance with the rules and statutes regarding workers222 compensation law. 8) Company agrees to cooperate in any review of this waiver. 9) Company agrees to notify the Idaho Industrial Commission of any change in third-party Claims Administrator designations, including any in-state Claims Administrator changes for each policy holder. Signature: Date: Title: (Type or print title) American LegalNet, Inc. www.FormsWorkFlow.com