Ic Form 6 - Summary Of Payments Non-Fatal Cases

ADVERTISEMENT

STATE OF IDAHO
SUMMARY OF PAYMENTS
NON-FATAL CASES
IC No. _________________
County:____________ SSN:_______________________
Surety Claim No.:_______________________ Policy Yr.____________
Injured Person:_________________________ Employer:_______________________
Address:
_________________________
Business:_______________________
_________________________
Address:________________________
Occupation:_____________________________
________________________
Character of Injury:__________________________________________________
Date of Injury:______________________
Weekly Wage:
_______________
Date RTW:
______________________
Comp. Rate:
_______________
Last check date:________________
INDEMNITY
MEDICALS
Dis-
$ Amounts
wks
days
Beginning
Last
Service
$ Amount
abil-
Date of
Date of
Type
-ity
Disability
Disability
$ Total
$/Wk rate
Type
DOCTOR
HOSP
PHYS TH
MILEAGE
MISC
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:
Industrial Commission Approval:
Surety:
________________________________
Adjuster: ________________________________
by:________________________Date:__________
IC FORM 6(7-1-97)

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form St-6 - Certificate Of Payment Of Sales Or Use Tax For Aircraft, Boat, Recreation Or Snow Vehicle - Massachusetts Department Of Revenue Form St-6 - Certificate Of Payment Of Sales Or Use Tax For Aircraft, Boat, Recreation Or Snow Vehicle - Massachusetts Department Of Revenue Financial
Form St-6 - Certificate Of Payment Of Sales Or Use Tax For Boat Recreation Or Snow Vehicle Form St-6 - Certificate Of Payment Of Sales Or Use Tax For Boat Recreation Or Snow Vehicle Financial
Form 44-007 - Annual Verified Summary Of Payments Report (vsp) - 2005 Form 44-007 - Annual Verified Summary Of Payments Report (vsp) - 2005 Financial
Form 44-007 - Annual Verified Summary Of Payments Report (vsp) - 2006 Form 44-007 - Annual Verified Summary Of Payments Report (vsp) - 2006 Financial
Form 44-007 - Annual Verified Summary Of Payments Report (vsp) - 2008 Form 44-007 - Annual Verified Summary Of Payments Report (vsp) - 2008 Financial
Form 44-007 - Annual Verified Summary Of Payments Report (vsp) - 2011 Form 44-007 - Annual Verified Summary Of Payments Report (vsp) - 2011 Financial
Form 44-007 - Annual Verified Summary Of Payments Report (vsp) - 2010 Form 44-007 - Annual Verified Summary Of Payments Report (vsp) - 2010 Financial
Form 44-007 - Annual Verified Summary Of Payments Report (vsp) - 2007 Form 44-007 - Annual Verified Summary Of Payments Report (vsp) - 2007 Financial
Form 44-007 - Annual Verified Summary Of Payments Report (vsp) - 2009 Form 44-007 - Annual Verified Summary Of Payments Report (vsp) - 2009 Financial
Form St-6 - Certificate Of Payment Of Sales Or Use Tax For Boat, Recreation Or Snow Vehicle Form St-6 - Certificate Of Payment Of Sales Or Use Tax For Boat, Recreation Or Snow Vehicle Financial

Related Categories

Parent category: Legal
Download
Go