STATE OF IDAHO SUMMARY OF PAYMENTS NON-FATAL CASES IC No. _________________ County:____________SSN:_______________________ Surety Claim No.:_______________________Policy Yr.____________ Injured Person:_________________________Employer:_______________________ Address: _________________________ Business:_______________________ _________________________ Address:________________________ Occupation:_____________________________ ________________________ Character of Injury:__________________________________________________ Date of Injury:______________________ Weekly Wage: _______________ Date RTW: ______________________ Comp. Rate: _______________ Last check date:________________ INDEMNITY MEDICALS Dis- $ Amounts wks days Beginning Last Service $ Amount abil- Date of Date of -ity Type Type $ Total $/Wk rate Disability Disability DOCTOR HOSP PHYS TH MILEAGE MISC 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: Industrial Commission Approval: Surety: ________________________________ Adjuster: ________________________________ by:________________________Date:__________ IC FORM 6(7-1-97)