COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. : Idaho Industrial Commission JUDICIAL SUBPOENA Plaintiff(s) -against- : APPLICATION FOR WAIVER : : Defendant(s) : ...................................................... DATE:_________________________ THE PEOPLE OF THE STATE OF NEW YORK COMPANY NAME:_________________________________________________ TO 1) ___________________________________ Name of Agent/Officer Title __________________________________ 2) GREETINGS: ______________________________________ Printed name of WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before at the Court 3) the Honorable ___________________________________City_____________________State______ZIP______ located at County of Company Home office Address in room , on the day of , 20 , at o'clock in the noon, and at any recessed 4) or adjourned date, to testify and give evidence as a witness in this action on the part of the ___________________________________City_____________________State______ZIP______ Mailing address if different than home office 5) If Idaho Workers’ Compensation Claims will be managed by a third party adjusters TPA, please Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to provide the on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a the party following information: result of your failure to comply. Name of TPA ________________________________________________ Witness, Honorable Court in County, , one of the Justices of the Address_________________________________City____________________State_____ZIP______ day of , 20 Telephone number ___________________________ or 1-800_______________________________ (Attorney must sign above and type name below) rd *Note If Company has more than one 3 party adjuster, include with the application a list of all policy holders who are not adjusted by this adjuster. The list should include the policy holder’s name Attorney(s) for and the name, address and telephone number of the adjuster designated for that policy holder. 6) Include with your application an original document signed by a banking institution which has branches in the State of Idaho, that guarantees checks drawn on your out-of state bank are negotiable upon presentation at a local bank. Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com , COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. : Idaho Industrial Commission JUDICIAL SUBPOENA Plaintiff(s) -against- : AFFIDAVIT IN SUPPORT OF APPLICATION FOR WAIVER : : I, the undersigned __________________________________, being duly sworn attest to the following: Defendant(s) : . . . . . . . . . . . . . . . . . (Type. or. print.name). . . . . . . . . . . . . . . . . . . . . . .... . ... .... 1) The information contained in Company’s application for Waiver and in this affidavit is complete and accurate to the best of my information and belief. THE PEOPLE OF THE STATE OF NEW YORK 2) I am an agent or officer authorized to act on behalf of _________________________ (Company) TO in this application for waiver. 3) Company is duly authorized to transact workers’ compensation insurance in Idaho. GREETINGS: 4) Company agrees to follow all statutes and regulations regarding workers’ compensation in the State of Idaho. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court 5) All adjusting and decisionslocated at payment of claims will be made within the State of Idaho by regarding County of Idaho licensed adjusters or staff claims examiners., at Idaho basedin the The or staff claims in room , on the day of , 20 o'clock adjusters noon, and at any recessed examiners are empowered to authorizeas a witness in this action on the part of the compensation checks. or adjourned date, to testify and give evidence 6) All of Company’s Idaho workers’ compensation claim files will be maintained with the State of Idaho. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a 7) Company agrees to cooperate with the Commission and provide information and documentation result of your failure to comply. as may from time to time requested in accordance with the rules and statutes regarding workers’ compensation law. Witness, Honorable Court in County, 20 8) Company agrees to cooperateday any review of ,this waiver. in of , one of the Justices of the 9) Company agrees to notify the Idaho Industrial Commission of any change in third-party (Attorney policy above and adjustment designations, including any TPA changes for each must sign holder. type name below) Attorney(s) for Signature:__________________________________________ Date:___________________________ Office and P.O. Address Title:______________________________________________ (Type or print title) Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Plaintiff(s) Calendar No. : JUDICIAL SUBPOENA IDAPA 17.02.03.051. REQUIREMENTS FOR MAINTAINING IDAHO WORKERS' -against: COMPENSATION CLAIMS FILES. All sureties, self-insured employers, and licensed adjustors servicing Idaho workers’ compensation claims : shall comply with the following requirements: : 01. Idaho Office. All sureties, self-insured employers and licensed adjusters servicing Idaho workers’ compensation claims shall maintain an office within: the state of Idaho. The offices shall be Defendant(s) . . . by . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . staffed. . . . adequate .personnel .to. conduct .business.. The. surety. or self-insured employer shall authorize a member of its staff or a licensed adjuster to make decisions regarding claims pursuant to Idaho Code, Section 72-305. As staffing changes occur and, at least annually, the surety, self-insured employer or licensedPEOPLE OF THE STATEto the Industrial Commission the names of those authorized to make THE adjuster shall submit OF NEW YORK decisions regarding claims pursuant to Idaho Code, Section 72-305. Answering machines, answering services, or toll free numbers outside of the state will not suffice. TO 02. Claim Files. All Idaho workers’ compensation claim files shall be maintained within the state of Idaho, or if maintained on an out-of-state computer, data must be entered from within the State. GREETINGS: Hard copies of data entry shall be maintained within the State. Claim files shall include, but are not limited to: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court a. Notice of Injury and Claim for Benefits; located at County of b. Copies ofthe forday of care; , 20 medical in room , on bills , at o'clock in the noon, and at any recessed or adjourned Copyto testify and give evidence asif applicable; action on the part of the date, of lost-time computations, a witness in this c. d. Correspondence reflecting reasons for any delays in payments (i.e., awaiting medical reports, clarification, questionable items on bills, etc.); Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to e. Employer’s this subpoena Report; and the party on whose behalf Supplemental was issued for a maximum penalty of $50 and all damages sustained as a result of yourMedical reports. failure to comply. f. Witness, Honorable , one of the Justices of the 03. Correspondence. All original correspondence regarding Idaho workers’ compensation Court in County, day of , 20 claims shall be mailed from and maintained at in-state offices. 04. office. Date Stamp. Each of the above shall be date-stamped on the day received by the claims (Attorney must sign above and type name below) 05. Notice And Claim. All Notices of Injury and Claims for Benefits, occupational illnesses Attorney(s) for and fatalities shall be sent directly to the in-state adjuster, surety, or self-insured employer. The original copy of the Notice of Injury and Claim for Benefits, occupational illness and fatality shall be sent directly to the Industrial Commission. 06. Compensation. “Compensation” is used collectively and means any or all of the income Office and P.O. Address benefits the medical and related benefits and medical services made under the provision of the Workers’ Compensation Act. All compensation must be issued from the in-state office. 07. prohibited. a. Checks And Drafts. Checks must be signed and issued within the state of Idaho; drafts are Telephone No.: Facsimile No.: E-Mail Address: However, the Commission may, upon receipt Mobile Tel. No.: of a written Application for Waiver, grant a American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. waiver from the provisions of Subsections 051.06 and 051.07 of: this rule to permit aSUBPOENA JUDICIAL surety or self-insured Plaintiff(s) employer to sign and issue checks outside the state of Idaho. -against- : b. An Application for Waiver must be accompanied by an affidavit signed by an officer or principal of the surety or self-insured employer, attesting to: the fact that the surety or self-insured employer is prepared to comply with all statutes and rules pertaining to prompt payments of : compensation. Defendant(s) : . . . . c. . . . . .All. waivers .shall .be. effective .from .the .date. the. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Commission issues the order granting the waiver. A waiver shall remain in effect until revoked by the Industrial Commission. At least annually, staff of the Industrial Commission may review the performance of any surety or self-insured employer for which aPEOPLE OF THE STATE OF NEW YORK to assure that the surety or self-insured employer is THE waiver under this rule has been granted complying with all statutes and rules pertaining to prompt payments of compensation. TO d. If at any time after the Commission has granted a waiver, the Commission receives information permitting the inference that the surety or self-insured employer has failed to provide timely benefits to any claimant, the Commission may issue an order to show cause why the Commission should notGREETINGS: revoke the waiver; and, after affording the surety or self-insured employer an opportunity to be heard, may revoke the waiver and order the surety or self-insured employer to comply with the requirements of WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Subsection 051.07 of this rule. , the Honorable at the Court located at County of 08. Copies Of Checks. Copies of checks and/or electronically reproducible copies of the in room , on the day , 20 , o'clock in the noon, and at any recessed information contained on the checksof must be maintained at the in-state files for Industrial Commission in or adjourned date, to testify and give evidence as a witness in this action on the part of the audit purposes. A copy of the first check, showing signature and date, shall be sent to the Industrial Commission the same day of issuance. 09. Your failure to comply with this subpoena is punishable as is contemptas: court and will make you liable to Prompt Claim Servicing. Prompt claim servicing a defined of the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of yourPayment of medical bills in accordance with the provisions of IDAPA 17.02.09.031 and failure to comply. a. 032 (formerly IDAPA 17.01.03.803.A and B); Witness, Honorable , one of the Justices of the Court in , 20 b. PaymentCounty, of income day of benefits on a weekly basis, unless otherwise approved by the Commission. 10. Audits. The Industrial Commission will perform periodic sign above and type name below) (Attorney must audits to ensure compliance with the above requirements. 11. Non-Compliance. Non-compliance with the above requirements may result in the Attorney(s) for revocation of the authority of an insurance company or self-insured employer to write workers’ compensation insurance in the state of Idaho, or such lesser sanctions as the Industrial Commission may impose. Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com