Report Of Litigation Expenses (Employer/surety/isif/self Insurers) printable pdf download

Report Of Litigation Expenses (Employer/surety/isif/self Insurers)

INDUSTRIAL COMMISSION

P. O. BOX 83720

BOISE, ID

83720-0041

I.C. CASE NO. ________________

I.C. CASE NAME _____________________________________________

_______________________________________________________

REPORT OF LITIGATION EXPENSES

(EMPLOYER/SURETY/ISIF/SELF INSURERS)

In accordance with the requirements of Section 72-528, Idaho Code,

this form shall be filled out and returned to the Industrial

Commission within 30 days following the time of entry of a final

award by the Industrial Commission in the above case, or, in the

event of an appeal to a final court, within 30 days following a

final ruling by the court.

If there is an appeal, the totals

specified below shall include the expenses, costs, or fees incurred

in the appeal.

Attorneys fees paid in case:

$_____________

Expenses charged by attorneys:

_____________

Charges for reports or testimony

of witnesses:

_____________

Cost of any depositions taken:

_____________

Cost of investigations made before

or during hearing:

_____________

Costs of research or legal briefs

(if separate from attorneys fees):

_____________

Filing fees paid on account of

the litigation:

_____________

TOTAL

$_____________

Dated this _______ day of __________________, 19 ____.

FIRM NAME_____________________________________________

BY____________________________________________________

Check Applicable Box:

___Self Insured

___ Uninsured Employer

___ Surety

___State Insurance Fund ___Industrial Special Indemnity Fund

IC Form 1023

IDAPA 17.02.05.281

Report Of Litigation Expenses (Employer/surety/isif/self Insurers)

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