Report Of Litigation Expenses (Employer-Surety-ISIF-Self Insureds) {IC-1023}

INDUSTRIAL COMMISSION P. O. BOX 83720 BOISE, ID 83720-0041 I.C. CASE NO. ________________ I.C. CASE NAME _____________________________________________ _______________________________________________________ REPORT OF LITIGATION EXPENSES (EMPLOYER/SURETY/ISIF/SELF INSURERS) In accordance with the require ments of Section 72-528, Idaho Code ,this form shall be filled out and returned to the Industrial Commission within 30 days following the time of entry of a final award by the Industrial Commission in the above case, or, in the event of an appeal to a final court, within 30 days following a final ruling by the court. If there is an appeal, the totals specified below shall include the expenses, costs, or fees i ncurredin the appeal. 1. Attorneys fees paid in case: $_____________ 2. Expenses charged by attorneys: _____________ 3. Charges for reports or testimony of witnesses: _____________ 4. Cost of any depositions taken: _____________ 5. Cost of investigations made before or during hearing: _____________ 6. Costs of research or legal briefs (if separate from attorneys fees): _____________ 7. Filing fees paid on account of the litigation: _____________ TOTAL $_____________ Dated this _______ day of __________________, 19 ____. FIRM NAME_____________________________________________ BY____________________________________________________ Check Applicable Box: ___Self Insured ___ Uninsured Employer ___ Surety ___State Insurance Fund ___Industrial Special Indemnity Fund IC Form 1023 IDAPA 17.02.05.281