Fill and Sign the Alabama Claim Compensation Form

MAIL TO: STATE OF ALABAMA Workers’ Compensation Division Department of Labor Montgomery, Alabama 36131 COMBINATION SUPPLEMENTARY & CLAIM SUMMARY FORM 1. Employee:       2. Social Security number: 3. Employer:       4. Unemployment Compensation Number:       5. Date of Injury:       6. Date disability began this period:       7. Insurance carrier:       8. Claim #       9. Service Co #       10. Name, address and telephone number of office filing this report: SUPPLEMENTAL REPORT FIRST PAYMENT REINSTATEMENT AMENDED A. 1. On       the amount of $       was paid for the period from       thru       (Date of 1 st check) Average Weekly Wage $       Compensation Rate $       per week. 2. Type of Disability: Temporary Total ; Temporary Partial ; Permanent Partial ; Permanent Total ; Fatal 3. If periodic payments were awarded by Circuit Court, give name, location and civil action (CV) number and explain:       B. COMPENSATION WAS NOT PAID WITHIN 30 DAYS FROM THE DATE OF DISABILITY BEGAN, COMPLETE THIS SECTION. 4. Reason for non-payment: Medical Only , no lost time (return to work date)       Under investigation , reason for prolonged investigation       In litigation , Under appeal 5. Has compensation been denied and claimant notified? Yes No Reason?       CLAIM SUMMARY FORM SUSPENSION SETTLEMENT AMENDED (DO NOT INCLUDE ANY PAYMENTS PREVIOUSLY FILED ON A CLAIM SUMMARY FORM) 1. Last day comp was owed and paid       RTW       MMI       2. Did claimant work during this period of disability? Yes No If so, from       to       total days       3. AWW $       CR (66.7%) $       4. Amount and type of comp paid: TTD $       WKS       Days       TPD $       WKS       PPD $       WKS       Days       %       POB       PTD $       WKS       Days       Death $       WKS       Days       Estate Payment $       Burial Payment $       LSP $       Date Pd       WKS       Days       %       Part of Body       5. Ombudsman Yes No Court CV#       Location (County)       Date       Adjuster & Title       Signature 10/01/2012