STATE OF IDAHO
SUMMARY OF PAYMENTS
NON-FATAL CASES IC No. _________________ County:____________ SSN:_______________________ Surety Claim No.:_______________________ Policy Yr.____________ Injured Person:_________________________ Employer:_______________________ Address: _________________________ _________________________ Occupation:_____________________________ Business:_______________________ Address:________________________ ________________________
Character of Injury:__________________________________________________ Date of Injury:______________________ Date RTW: ______________________ Weekly Wage: Comp. Rate: _______________ _______________
Last check date:________________ INDEMNITY
Disabil-ity Type
MEDICALS
wks days Beginning Date of Disability Last Date of Disability
$ Amounts
$ Total
$/Wk rate
Service Type DOCTOR HOSP PHYS TH MILEAGE MISC
$ Amount
Note: A new period of disability must be itemized each time Comp Rate changes; or Type of Disability changes; or there is a break in continuity.
Notes: Surety: ________________________________
Industrial Commission Approval:
Adjuster: ________________________________ by:________________________Date:__________
IC FORM 6(7-1-97)