Free SOP - Idaho

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)