Free Report of Outstanding Awards - Idaho

INSTRUCTIONS
Every FATAL, PERMANENT TOTAL AND PERMANENT PARTIAL case on which compensation is being paid by your company, must be entered on this form and carried forward on subsequent reports until paid out. New cases will be entered as they are determined and carried forward on the next report. (Be sure to disregard all Total Temporary cases.) File report by the 10th of the month. HEADING: PRINT NAME OF INSURER OR SELF-INSURED EMPLOYER, YEAR AND SELECT CALENDAR ENDING QUARTER. COLUMN 1. DATE OF INJURY COLUMN 2. NAME OF INJURED EMPLOYEE COLUMN 3. CLASS OF DISABILITY Enter in this column the kind of case; i.e., FATAL, PERMANENT TOTAL, OR PERMANENT PARTIAL. (Use Abbreviations) COLUMN 4. TOTAL AWARDS Include total compensation and other expenses as shown on the approved Summary of Payments and/or Reserves established for Permanent Totals. COLUMN 5. COMPENSATION PAID Enter the amount paid on each case since the last report was filed. COLUMN 6. TOTAL COMPENSATION PAID Enter the total amount paid on the award, including amount shown in column 5. COLUMN 7. ADJUSTMENT Make all adjustments for changes of conditions, remarriage, deaths, errors, etc. in this column. If adjustments are made, then column 4 must equal column 6 plus or minus column 7 plus column 8. COLUMN 8. UNPAID BALANCE This will show the balance due on each case.

THIS FORM MUST BE COMPLETED AND EXECUTED DIRECTLY BY THE SURETY OR SELF-INSURED EMPLOYER

MAIL TO: IDAHO INDUSTRIAL COMMISSION FISCAL SECTION P. O. BOX 83720 BOISE, ID 83720-0041 PHYSICAL ADDRESS: IDAHO INDUSTRIAL COMMISSION FISCAL SECTION 700 S CLEARWATER LANE BOISE, ID 83712

IC 36, REPORT OF OUTSTANDING AWARDS FOR FATAL, PERMANENT PARTIAL IMPAIRMENT, AND PERMANENT TOTAL DISABILITY CLAIMS

(Name of Insurer or Self-Insured Employer) Year: __________ For Calendar Quarter Ending:
(1) Date Of Injury (2) Claimant Name (as shown on First Report of Injury) (3) Type of Claim

March
(4) Total Awards

June
(5) Compensation on this Report

September
(6) Total Compensation Paid

December
(7) Adjustment (8) Unpaid Balance

Total Send Original to: Fiscal Section, Industrial Commission, P.O. Box 83720, Boise, Idaho 83720-0041

_________________________________________________________________________________________________________ Corporate Officer's Signature and Title Printed Name Date: __________________________ Print Name and Title of Preparer: ______________________________ Company: ____________________________________________ Address: _____________________________________________ Telephone: ___________________________________________ Page ________ of _________