REQUEST FOR WORKERS' COMPENSATION RECORDS BY PARTIES (* = COMPLETION MANDATORY) Under the provisions of Idaho Code � 74-105(10)(a), the undersigned requests a copy of the workers' compensation records of the Idaho Industrial Commission identified below. Requester agrees to pay all billable costs incurred in responding to this request under the Idaho Public Records Law. Claimant's Full Name:* __________________________________ Claimant's Social Security Number:* __ __ __-__ __-__ __ __ __ Date(s) of injury:* ___________________________________ I.C. Claim Number: Records Requested:* Claims History Search, including IC claim status for: The past 5 years. The above noted claim. ___ ___-___ ___ ___ ___ ___ ___ I.C. RESPONSE/NOTE AREA: Employer: __________________________________________ The past ____ year period. Hardcopy of Electronic First Report of Injury for: 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 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. Copy of other workers' compensation records (Specify): Rehabilitation records Adjudication records (closed files only) Other records (Describe): _______________________________________ separate submission of form RMR-6) The claimant, (NOTE: Requests for workers' compensation records on claims closed prior to January 1, 2004 will require a The undersigned party is (check all applicable boxes):* in an open claim involving one of the parties in the records requested, or in the closed claim(s) requested above. the employer, the surety, or the ISIF, Full name of party:* _____________________________________________ Full name of legal representative:* _____________________________________________ _____________________________________________ Mailing Address for response:* _____________________________________________ _____________________________________________ _____________________________________________ * Requester's Phone #/Email: (____) ______________/__________________ Requester's Signature:*# ___________________________________________ Date Signed:* ________________________ (# = Must be signed personally by legal representative) I.C. Records Form RMR-1 SEND COMPLETED REQUEST TO: IDAHO INDUSTRIAL COMMISSION, ATTN: RECORDS MANAGEMENT, PO BOX 83720, BOISE, ID 83720-0041 FAX: 208-334-2321 American LegalNet, Inc. www.FormsWorkFlow.com Revised: September, 2015