g. State of Idaho-Certificate-of-Verification of Workers Compensation Insurance-Form.pdf

STATE OF IDAHO CERTIFICATE OF VERIFICATION OF WORKERS’ COMPENSATION INSURANCE

Date: ____ /____ /________

Contractor Information

Contractor's Legal Business Name: _______________________________________________________________

Contractor's Federal Identification Number or Social Security Number: _________________________________

Contractor's Business Address:

Street: ________________________________________ City: ____________ State: _____ Zip: ____________

Contractor's Telephone Number: (_____) ______ - __________

Contractor's Home Address:

Street: ________________________________________ City: ____________ State: _____ Zip: ____________

Contractor’s Email Address: _____________________________________________________________________

Legal Business Entity (Select one business entity type from list below)

Sole Proprietor

Partnership/Limited Liability Company

Corporation

Other – Please explain: __________________________________________________________________

Workers’ Compensation Insurance

Do you have Workers’ Compensation Insurance? Yes No

Carrier: _____________________________________________

Policy Number: _______________________________________

Effective Date: ____ /____ /________

Project Details

List the approximate number of workers who are not exempt owners who will be working on this project: ______

Workers who are not exempt owners must be covered under an Idaho Workers’ Compensation Policy. This may include spouses and other family members. For more information about exemptions please visit iic.idaho.gov.

Contract #: ___________________________

Estimated Start Date: ____ /____ /________

Project Location: ______________________________________________________________________________

Description of Work: ___________________________________________________________________________

Forest Service Office Overseeing Contract: _________________________________________________________

Forest Service Contact Name: ___________________________________________________________________

Forest Service Contact Email Address: _____________________________________________________________ https://iic.idaho.gov/

Note: All sub-contractors used on this contract must also complete a certificate of verification of workers’ compensation insurance prior for approval before your business commences work on this project. See Title 72-216 of Idaho code to see how this might impact your business.

Do you intend to use and contractors to assist you with the performance of this contract? Yes No

I CERTIFY that the above information is true and correct to the best of my knowledge. 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.

Name: _______________________________ Signature: _____________________________ Date: ____ /____ /________

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’s:

Certification is approved

Contractor is not required to provide proof insurance coverage because contractor will only use exempt owners in performance of their contract with the USFS.

Contractor provided proof of current workers’ compensation insurance as required by state law.

Certification is Denied

Contractor does not meet Idaho’s coverage requirements as set forth under Title 72-301 of Idaho code.

Failed to complete certificate of verification.

Subcontractor failed to complete certificate of workers’ compensation insurance.

Industrial Commission Compliance Officer Signature

Date: ____ /____ /________

Contract/Solicitation # _______________________________