STATE OF IDAHO CERTIFICATE OF VERIFICATION OF WORKERS COMPENSATION INSURANCE Read thoroughly before completing form . WHAT ARE THE WORKERS COMPENSATION REQUIREMENTS? The Idaho Workers Compensation Law requires that employers who hire one or more, either full or part-time employees, to perform work in the State of Idaho, carry workers compensation insurance unless specifically exempted. Failure to comply could result in monetary penalties as well as an injunctionto prohibit the employer from operating the business. Failure to carry workers compensation insurance for employees is a misdemeanor under Idaho Law. WHO MUST COMPLETE THIS FORM? Any person, partnership, limited liability company, corporation or firm who is bidding on a contract for the United States Department of Agriculture/Forest Service (US FS) for work that is within the State of Idaho and who has been notified by the USFS that he/she/it has been selected for a USFS contract. WHEN MUST THE FORM BE COMPLETED? The form must be completed and forwarded to one of the Industrial Commission offices when you are notified by the USFS that you have been selected for a USFS contract. The approval of the Industrial Commission is required prior to the final award. ADDITIONAL COMMENTS: Failure to complete any part of the form that is applicable to your operations could result in a delay in processing. If any of the work is to be performed by sub-contractors, each sub-contractor must obtain and complete a Certificate of Verification of Workers Compensation Insurance. If your business is a partners hip, limited liability company or corporation, each partner/member/corporate officer must sign the form where designated. You must submit a separate verification form for each contract awarded. ONCE THE BIDDER HAS COMPLETED AND SIGNED THE FORM, FAX, MAIL OR DELIVER IT TOTHE APPROPRIATE INDUSTRIAL COMMISSION OFFICE. IF YOU HAVE ANY QUESTIONS, CONTACT A COMPLIANCE REPRESENTATIVE AT ANY OF THE FOLLOWING OFFICES: North Idaho 1221 Ironwood Street, Suite 100 COEUR DALENE ID 83814 (208) 769-1565 or FAX (208) 769-1465 Southwest Idaho 317 Main Street P O BOX 83720, BOISE ID 83720-0041 (208) 334-6032 or 1-800-950-2110 or FAX (208) 334-5145 Southeast Idaho 1070 Hiline, Suite 300 POCATELLO ID 83201 (208) 236-6366 or FAX (208) 236-6040 >>>> 2 FOR I.C. USE ONLY STATE OF IDAHO CERTIFICATE OF VERIFICATION IC# __________________ OF WORKERS COMPENSATION INSURANCE Received _____________ Date: ___________________ 1. Contractors Name ____________________________________________________________________ 2. Business Name ________________________________________________________________________ 3. Contractors Federal Identification Number ___________________________________________ 4. Contractors Business Address ________________________________________________________ Street, Box # City, State Zip 5. Contractors Business Telephone Number _______________________________________________ 6. Contractors Home Address ____________________________________________________________ Street, Box # City, State Zip 7. Name of Supervisor in charge of project ______________________________________________ 8. Supervisors Business Address ________________________________________________________ Street, Box # City, State Zip 9. Supervisors Business Telephone ______________________________________________________ 10. Supervisors Home Address ____________________________________________________________ Street, Box # City, State Zip 11. Classification of Business (a) G Corporation (List names, addresses & telephone numbers of corporate officers and directors, and percent of ownership.) (b) G Partnership/Limited Liability Company (List partner/member names, addresses, telephone numbers, and percent of ownership.) (c) G Sole Proprietorship (d) G Other - Please explain Description of Project 12. Contract # ______________________________________ Estimated Start Date______________ 13. Location of Work_____________________________________________________________________ 14. Description of Work _________________________________________________________________ 15. Forest Service District Office Overseeing Contract __________________________________ 16. DO YOU HAVE WORKERS COMPENSATION INSURANCE? G Yes G No 1. 11/27/96>>>> 317. Workers Compensation Insurance Company Name of Carrier____________________________________________________________________ Policy # ____________________________________ Effective Date ______________________ Name of Agent ________________________________ Tel. # ______________________________ Address ____________________________________________________________________________ Street, Box City, State Zip Extraterritorial Coverage #_________________________________________________________ State ______________ Date Approved _______________ Expiration Date _____________ 18. If Contractor is a sole proprietorship/partnership/limited liability company , will workers other than the proprietor or partners/members be performing any of the work to be done under this contract? G Yes G No a. If yes , state the approximate number of such workers and, if known, their names, permanent addresses, telephone numbers, and date of hire. (Attach additional pages, if needed.) 19. If Contractor is a corporation , will workers who are not officers and 10% shareholders and directors of the corporation be performing any of the work to be done under this contract? G Yes G No If yes , state the approximate number of such workers and, if known, their names, permanent addresses, telephone numbers, and date of hire. (Attach additional pages, if needed.) 20. Do you intend to use any sub-contractors to assist you in the performance of this contract? Note: All sub-contractors used on this contract must also submit a Certificate of Verification of Workers Compensation Insurance for approval prior to commencing work on this contract. G Yes G No If yes , state their names, business names, permanent addresses and telephone numbers. 21. Based upon my knowledge of the work to be performed under the contract specified on page 1 and upon my knowledge of work practices, methods and technologies to be applied during this contract, I estimate that __________ workers are necessary to do the work in the time prescribed, assuming average production rates and conditions. 22. I certify that the above information is true and correct to the best of my knowledge and beli