Authorization To Release Claims History
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Authorization To Release Claims History Form. This is a Idaho form and can be use in Record Request Workers Compensation.
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Tags: Authorization To Release Claims History, RMR-3, Idaho Workers Compensation, Record Request
AUTHORIZATION TO RELEASE CLAIMS HISTORY
In accordance with the provisions of Idaho Code §9-34OB(10)(b), the undersigned requests a
copy of a computer claims history search of the last five (5) years of the workers' compensation records of
the Idaho Industrial Commission for the worker identified below. Requestor agrees to pay all billable
costs incurred in responding to this request under the Idaho 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:
IC RESPONSE/NOTE AREA:
Employer’s Representative or Agent’s Signature*:
Printed Name & Title*:
Representative’s or Agent’s Phone Number*:
(
)
Employer/Prospective Employer or Agent*:
Mailing Address*:
(*=Completion Mandatory)
I.C. Records Form RMR-3
SEND COMPLETED REQUEST TO:
IDAHO INDUSTRIAL COMMISSION
ATTN: RECORDS MANAGEMENT
PO BOX 83720 BOISE, ID 83702-0041
Revised: 04/16/09
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