Attach_4_Workman's_comp_sheet_with_link.pdf

STATE OF IDAHO CERTIFICATE OF VERIFICATION

OF WORKERS' COMPENSATION INSURANCE

Read thoroughly before completing form.

WHAT ARE THE WORKERS' COMPENSATION REQUIREMENTS?

The Idaho Workers' Compensation Law requires that employers who hire one or more, either full or part-time employees, to perform work in the State of Idaho, carry workers' compensation insurance unless specifically exempted. Failure to comply could result in monetary penalties as well as an injunction to prohibit the employer from operating the business. Failure to carry workers' compensation insurance for employees is a misdemeanor under Idaho Law.

WHO MUST COMPLETE THIS FORM?

Any person, partnership, limited liability company, corporation or firm who is bidding on a contract for the United States Department of Agriculture/Forest Service (USFS) for work that is within the State of Idaho and who has been notified by the USFS that he/she/it has been selected for a USFS contract.

WHEN MUST THE FORM BE COMPLETED?

The form must be completed and forwarded to one of the Industrial Commission offices when you are notified by the USFS that you have been selected for a USFS contract. The approval of the Industrial Commission is required prior to the final award.

ADDITIONAL COMMENTS:

Failure to complete any part of the form that is applicable to your operations could result in a delay in processing.

If any of the work is to be performed by sub-contractors, each sub-contractor must obtain and complete a Certificate of Verification of Workers' Compensation Insurance.

If your business is a partnership, limited liability company or corporation, each partner/member/corporate officer must sign the form where designated.

You must submit a separate verification form for each contract awarded.

ONCE THE BIDDER HAS COMPLETED AND SIGNED THE FORM, FAX, MAIL OR DELIVER IT TO THE

APPROPRIATE INDUSTRIAL COMMISSION OFFICE. IF YOU HAVE ANY QUESTIONS, CONTACT A

COMPLIANCE REPRESENTATIVE AT ANY OF THE FOLLOWING OFFICES:

1111 Ironwood Street Suite A 847 Parckcenter Way Suite 7

COEUR D'ALENE ID 83814 NAMPA ID 83651

(208) 769-1452 or FAX (208) 769-1465 (208) 442-8341 or FAX (208) 442-8344

1070 Hiline Suite 300 1411 Falls Ave. East Suite 915

POCATELLO ID 83201 TWIN FALLS ID 83301

(208) 236-6399 or FAX (208) 236-6040 (208) 736-4700 or FAX (208) 736-3053

P.O. Box 83720

BOISE ID 83720-0041

(208) 334-6000 or 1-800-950-2110 or FAX (208) 334-5145 https://iic.idaho.gov/wp-content/uploads/sites/16/2018/01/ic_wc_verification.pdf

1. 11/27/96

FOR I.C. USE ONLY

IC# __________________

Received _____________

STATE OF IDAHO

CERTIFICATE OF VERIFICATION

OF WORKERS' COMPENSATION INSURANCE

Date: ___________________

1. Contractor's Name ____________________________________________________________________

2. Business Name ________________________________________________________________________

3. Contractor's Federal Identification Number ___________________________________________

4. Contractor's Business Address ________________________________________________________ Street, Box # City, State Zip

5. Contractor's Business Telephone Number _______________________________________________

6. Contractor's Home Address ____________________________________________________________ Street, Box # City, State Zip

7. Name of Supervisor in charge of project ______________________________________________

8. Supervisor's Business Address ________________________________________________________ Street, Box # City, State Zip

9. Supervisor's Business Telephone ______________________________________________________

10. Supervisor's Home Address ____________________________________________________________ Street, Box # City, State Zip

11. Classification of Business

(a) G Corporation (List names, addresses & telephone numbers of corporate officers and directors, and percent of ownership.)

(b) G Partnership/Limited Liability Company (List partner/member names, addresses, telephone numbers, and percent of ownership.)

(c) G Sole Proprietorship

(d) G Other - Please explain

Description of Project

12. Contract # ______________________________________ Estimated Start Date______________

13. Location of Work_____________________________________________________________________

14. Description of Work _________________________________________________________________

15. Forest Service District Office Overseeing Contract __________________________________

16. DO YOU HAVE WORKERS' COMPENSATION INSURANCE? G Yes G No

Attachment #6 12026119R0001

2. 11/27/96

17. Workers' Compensation Insurance Company

Name of Carrier____________________________________________________________________

Policy # ____________________________________ Effective Date ______________________

Name of Agent ________________________________ Tel. # ______________________________

Address ____________________________________________________________________________ Street, Box City, State Zip

Extraterritorial Coverage #_________________________________________________________

State ______________ Date Approved _______________ Expiration Date _____________

18. If Contractor is a sole proprietorship/partnership/limited liability company , will workers other than the proprietor or partners/members be performing any of the work to be done under this contract?

G Yes G No

a. If yes , state the approximate number of such workers and, if known, their names, permanent addresses, telephone numbers, and date of hire. (Attach additional pages, if needed.)

19. If Contractor is a corporation , will workers who are not officers and 10% shareholders and directors of the corporation be performing any of the work to be done under this contract?

G Yes G No

If yes , state the approximate number of such workers and, if known, their names, permanent addresses, telephone numbers, and date of hire. (Attach additional pages, if needed.)

20. Do you intend to use any sub-contractors to assist you in the performance of this contract? Note: All sub-contractors used on this contract must also submit a Certificate of Verification of Workers' Compensation Insurance for approval prior to commencing work on this contract.

G Yes G No

If yes , state their names, business names, permanent addresses and telephone numbers.

21. Based upon my knowledge of the work to be performed under the contract specified on page 1 and upon my knowledge of work practices, methods and technologies to be applied during this contract, I estimate that __________ workers are necessary to do the work in the time prescribed, assuming average production rates and conditions.

22. I certify that the above information is true and correct to the best of my knowledge and belief. Further, I agree to inform the Industrial Commission Compliance Officer if there is any change in the above information during the time this contract is in effect.

3. 11/27/96

Type or Print Contractor's Name

By: ___________________________________________ Signature

Date: _________________________________________

23. If the business is a partnership, limited liability company or corporation, this document requires the signature of all of the partners/members/corporate officers.

(Attach additional pages if necessary.)

___________________________________________________________ Date _________________ Partner/Member/Corp. Off. Title % of Ownership

___________________________________________________________ Date _________________ Partner/Member/Corp. Off. Title % of Ownership

___________________________________________________________ Date _________________ Partner/Member/Corp. Off. Title % of Ownership

___________________________________________________________ Date _________________ Partner/Member/Corp. Off. Title % of Ownership

CONTRACTOR - DO NOT WRITE BELOW THIS LINE

Based solely upon the assertions above set forth, and without warranty of continued compliance, the Idaho Industrial Commission finds that Contractor:

G Currently carries workers' compensation insurance as required by state law.

G Has a current extraterritorial on file from the State of ______________ which covers only _________________ based employees while working temporarily in the State of Idaho. Extraterritorial coverage expires __________________.

G Is not required to provide workers' compensation insurance because:

G Is a partnership/limited liability company/sole proprietor which employs no workers other than the partners/members/sole proprietor and will not employ any other workers under this contract.

G Is a corporation which employs no workers other than individuals who are corporate officers, directors and 10% shareholders and will not employ any other workers under this contract.

G Other (Specify) :

(By making the above finding, the Commission does not warrant continued compliance.)

G Has not obtained the required workers' compensation insurance.

Industrial Commission Compliance Officer

Date___________________________________

Contract/Solicitation # ________________