Idaho > Workers Compensation > Adjuster
Summary Of Payments Fatal Case IC-6F - Idaho
| Summary Of Payments Fatal Case Form. This is a Idaho form and can be used in Adjuster Workers Compensation . |
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Accident No. SUMMARY OF PAYMENTS FATAL CASE Claim No. Injured Person Employe Address Business Address Occupation Premiums paid to Character of Injury Date of Accident Actual Weekly Wages $ Date of Death DEPENDENTS Name of Dependents Relationship Date of Birth (IF UNDER 18) AWARDS OF PAYMENTS Compensation Payments % Wages Amount Weeks Total Remarks SEE ATTACHED RE VISION Total Compensation Payments BURIAL AND OTHER EXPENSES Payment to For Funeral Expenses $ Payment to For Medical Expenses $ Payment to For $ Payment to For $ Total Miscellaneous $ Checked Approved , 20 Auditor CLAIM EXAMINER Claims Mgr. Member
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