workers_comp_form.doc

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:

North Idaho 1221 Ironwood Street, Suite 100

COEUR D'ALENE ID 83814

(208) 769-1565 or FAX (208) 769-1465

Southwest Idaho 317 Main Street

P 0 BOX 83720, BOISE ID 83720-0041

(208) 334-6032 or 1-800-950-2110 or FAX (208) 334-5145

Southeast Idaho 1070 Hiline, Suite 300

POCATELLO ID 83201

(208) 236-6366 or FAX (208) 236-6040

STATE OF IDAHO

CERTIFICATE OF VERIFICATION

OF WORKERS' COMPENSATION INSURANCE

FOR I.C. USE ONLY

IC#

Received

Date:_____________________

1. Contractor’s Name:_________________________________________________________________________

2. Business Name: ___________________________________________________________________________

3. Contractor’s Federal Identification Number: _____________________________________________________

4. Contactor’s Business Address: _______________________________________________________________ Street, Box # City, State Zip

5. Contractor’s Business Telephone Number: ______________________________________________________

6. Contractor’s Home Address: _________________________________________________________________

7. Name of Supervisor in charge of project: _______________________________________________________

8. Supervisor’s Business Address: ______________________________________________________________

9. Supervisor’s Business Telephone: _____________________________________________________________

10. Supervisor’s Home Address: ________________________________________________________________

11. Classification of Business

(a)

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

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

(c) Sole Proprietorship

(d) 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: _ Clearwater National Forest, Orofino, ID ____________

16. DO YOU HAVE WORKERS’ COMPENSATION INSURANCE? Yes No

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?

Yes 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.)

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?

Yes 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 in this contract.

Yes 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 may 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.

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:

Currently carries workers’ compensation insurance as required by state law.

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 .

Is not required to provide workers’ compensation insurance because:

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.

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.

Other (Specify):

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

Has not obtained the required workers’ compensation insurance.

Industrial Commission Compliance Officer

Date _________________________________ Contract/Solicitation#___________________