Free I - Idaho

Accident No.

SUMMARY OF PAYMENTS
FATAL CASE
Injured Person Address Occupation Premiums paid to Character of Injury Employe Business Address Claim No.

Date of Accident Date of Death

Actual Weekly Wages $

DEPENDENTS
Name of Dependents Relationship Date of Birth (IF UNDER 18)

AWARDS OF PAYMENTS
Compensation Payments SEE ATTACHED REVISION % Wages Amount Weeks Total Remarks

Total Compensation Payments
BURIAL AND OTHER EXPENSES Payment to Payment to Payment to Payment to For Funeral Expenses For Medical Expenses For For Total Miscellaneous Checked Approved $ $ $ $ $ , 20

CLAIM EXAMINER

Claims Mgr.

Auditor

Member