Employer's Supplemental Report
An Employer's Supplemental Report (IC Form 14) must be completed and mailed to the State Insurance Fund and the Industrial Commission when
any of the following occur:
- The injured worker has returned to work regardless of the length of time unable to work.
- The injured worker is unable to work after 60 days.
An additional request may be made by the State Insurance Fund's Claims Department when it is necessary to document information
from a physician or secure additional information to further assess the need for rehabilitation services.
Download the form
Using Word
If you use Word, you can download the Supplemental Report form, complete it on your computer,
and return it to us via e-mail as an attachment. Send your e-mail to
To download:
- Click on the link below
- Go to the menu bar of your browser, and click on "File" followed by "Save As"
- Save the file in the folder of your choice on your computer
Employers Supplemental Form
Using an Adobe Acrobat PDF
Don't use Word? You still can download the form in PDF format, print it out, complete it neatly, and mail or fax it to us.
Adobe Acrobat Reader, which reads PDFs, is available for free.
Employers Supplemental Form
Fax to 208-332-2171
Completing the form
The second line on the right indicates the date disability began. This is the date the injured worker started losing time
from work as a result of an injury. If the injured worker has been off work and returned to work and is now unable to work again,
this date should reflect the second time-loss period.
If the claimant has returned to modified duty at a lower wage, the lower wage should be reflected in the line titled "At
What Daily Wage." Explain the claimant's work status on the line below the daily wage.
Failure to file a supplemental report could result in a fine being assessed against the employer by
the Industrial Commission for up to $500.
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