Print Form EMPLOYER CERTIFICATE AND REQUEST FOR CLAIMS HISTORY ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ In accordance with the provisions of Idaho Code § 9-340B(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. The undersigned certifies that the requestor is the employer or prospective employer of the identified worker and that an offer of employment for the job identified below has already been extended to said worker. The undersigned certifies further that the requested information will only be used in accordance with the provisions of the Americans with Disabilities Act (42 U.S.C. 12112) or other statutory limitations. The undersigned acknowledges that this certificate is made under oath and subject to the provisions of Idaho Code § 18-5401, regarding false statements made under oath. ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ Worker’s Full Name:* Other Names Used: Worker’s Address:* Worker’s Home Phone #: _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ (____) ______________________ Worker’s Social Security Number:* __ __ __-__ __-__ __ __ __ Description of Job Offered to this Worker:* _________________________________________. Start Date of Job Offered:* ______________________. Requestor’s (Employer’s) Name:* Mailing Address:* ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ Certified By (Signature):* _______________________________ Printed Name & Title*: _______________________________ STATE OF _____________________ County of ______________________ I.C. RESPONSE/NOTE AREA: ) ) ss. ) SUBSCRIBED AND SWORN TO Before me this _______ day of ______________________, ________. ___________________________________________________ NOTARY PUBLIC for ______________________ Residing at: ______________________________ SEND COMPLETED REQUEST TO: IDAHO INDUSTRIAL My Commission Expires: ___________________ COMMISSION, ATTN: RECORDS MANAGEMENT, PO BOX 83720, BOISE, ID 83720-0041 (* = Completion mandatory) I.C. Records Form RMR-2 Revised: March 1, 2009 American LegalNet, Inc. www.FormsWorkFlow.com