CLAIMANT'S REQUEST FOR PERSONAL WORKERS' COMPENSATION RECORDS In accordance with the provisions of Idaho Code � 74-113, the undersigned requests a copy of their own workers' compensation claims from the records of the Idaho Industrial Commission, as described below. Requester agrees to pay all billable costs incurred in responding to this request under the Idaho Public Records Law. (* = COMPLETION MANDATORY ) Requester's Full Name:* Other Names Used: Social Security Number:* Date(s) of Injury:* I.C. Claim Number: Mailing Address:* Phone #/Email:* Records Requested:* Claims History Search, including IC claim status for: The past 5 years. The past ____ year period. ____________________________ ____________________________ __ __ __-__ __-__ __ __ __ ____________________________ ___ ___-___ ___ ___ ___ ___ ___ ____________________________ ____________________________ (____) _______________/ I.C. RESPONSE/NOTE AREA: Hardcopy of Electronic First Report of Injury for: The above noted claim. All open claims in requested Claims History Search and all claims closed after January 1, 2004. (NOTE: Only Hard Copy First Reports on claims closed by the Commission after January 1, 2004 are available with this request. Requests for First Reports on claims closed prior to January 1, 2004 will require submission of form RMR-6) Hardcopy of claim file contents of: The above noted claim. All open claims in requested Claims History Search and all claims closed after January 1, 2004. Adjudication records (closed files only) A copy of other workers' compensation records (Specify): Rehabilitation records Other records (Describe): (NOTE: Requestsafor workers' compensation records on claims closed by the Commission prior to January 1, 2004 will require separate submission of form RMR-6) The undersigned requests that this information be provided directly to: (Name) ____________________________________________ at: (Address) __________________________________________________________ __________________________________________________________________, acting as agent for requester. Requesting Individual's Signature:* ___________________________________________ Date Signed:* ________________________ SEND COMPLETED REQUEST TO: IDAHO INDUSTRIAL COMMISSION, ATTN: RECORDS MANAGEMENT, PO BOX 83720, BOISE, ID 83720-0041 FAX: 208-334-2321 I.C. Records Form RMR-4 American LegalNet, Inc. www.FormsWorkFlow.com Revised: September, 2015