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) (2) (3) ( ) March (4) ( ) June (5) ( ) September (6) ( ) December (7) (8) Date of Injury Employee Name (as shown on First Report of Injury) Type Of Claim Total Award Compensation This Total Compensation Report Paid Paid Net Adjustments Unpaid Balance 1 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Total $0.00 $0.00 $0.00 $0.00 $0.00 Send Originals to: Fiscal Section, Industrial Commission, P.O. Box 83720, Boise, Id. 83720-0041 I certify this report is true and correct to the best of my knowledge. Corporate Officer's Signature Date: Name and Title of Preparer: Company: Address: Telephone: Printed Name and Title American LegalNet, Inc. www.FormsWorkFlow.com