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Report Of Outstanding Awards For Fatal Permanent Partial Impairment And Permanent Total Disability Claims IC-36 - Idaho

Report Of Outstanding Awards For Fatal Permanent Partial Impairment And Permanent Total Disability Claims Form. This is a Idaho form and can be used in Surety Workers Compensation .
 Fillable pdf Last Modified 7/27/2005
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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 rwardfo on the next report. (Be sure to disregard all Total Temporary cases.) th File report by the 10 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. CLAS S 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 column 7 Plus column 8. COLUMN 8. UNPAID BALANCE This will show the balance due on each case. THIS FORM MUST BE COMPLETED AND EXECU TED 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 317 MAIN STREET BOISE, ID 83702 <<<<<<<<<********>>>>>>>>>>>>> 2 IC 36, REPORT OF OUTSTANDING AWARDS FOR FATAL, PERMANENT PARTI AL IMPAIRMENT, AND PERMANE NT TOTAL DISABIL ITY CL AIMS (Name of Insurer or Self-Insured Employer) Year: __________ For Calendar Quarter Ending: March June September December (1) (2) (3) (4) (5) (6) (7) (8) Date Claimant Name Type Total Compensation Total Adjustment Unpaid Of (as shown on of Awards on this Compensation Balance Injury First Report Claim Report Paid of Injury) Total Send Original to: Fiscal Section, Industrial Commission, P.O. Box 83720, Boise, Idaho 83720-0041 ________________________________________________________________________ _________________________________ Corporate Officers Signature and Title Printed Name Date: __________________________ Print Name and Title of Preparer: ______________________________ Company: ____________________________________________ Address: _____________________________________________ Telephone: ___________________________________________ Page ________ of _________
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