Fill and Sign the Alabama Workers Form

THE USE OF THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE ALABAMA WORKMEN’S COMPENSATION LAW WCC Form 2 Rev. 10/2012 STATE OF ALABAMA EMPLOYER’S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE CLAIM REFERENCE 1. Insured Report Number       2. Filing Office Claim Number       3. OSHA Log Case Number       EMPLOYER 4. Employer Business Name       5. Physical Address 1       6. Physical Address 2       7. City       8. State       9. Zip       ADDRESS, IF LOCATION DIFFERENT FROM BUSINESS ADDRESS 10. Mailing Address 1       11. Mailing Address 2       12. City       13. State       14. Zip       15. Federal ID Number        16. U.C. Account Number        17. NAICS        INSURER / FILING OFFICE 18. Insurer Name       19. Insurer Federal ID Number         20. Type Insurer Ins Co Self-Insurer Group Fund 21. Filing Office Name       22. Mailing Address 1       23. Mailing Address 2 or Telephone Number        24. City       25. State       26. Zip       27. Filing Office Federal ID Number      EMPLOYEE / WAGES 28. First Name       29. Middle Name       30. Last Name       31 Last Name Suffix (ie. Jr., Sr., III)       32. Employee ID Number       33. Type Employee ID Number SSN Passport Number Green Card Employment Visa Assigned by Jurisdiction 34. Mailing Address 1       35. Mailing Address 2       36. City       37. State       38 . Zip       39. Phone       40. Gender Male Female 41. Date of Birth   42.Nbr of Dependents       43. Marital Status Unmarried (Single or Divorced or Widowed) Married Separated Unknown 44. Date Hired   45. Occupation Description       46. Number of Days Worked Per Week       47. Wages $       48. Hourly Daily Weekly Bi-weekly Monthly 49. Received Full Pay For Day of Injury? Yes No 50. Did Salary Continue? Yes No INJURY / TREATMENT 51. Date of Injury       52. Time of Injury       a.m. p.m. unk 53. Time Employee Began Work        a.m. p.m. 54. Date Disability Began   55. Date of Death   PLACE OF ACCIDENT, INJURY, OR EXPOSURE 56. Site Address       57. City       58. State       59. Zip        60. County       61. Injury Occurred on Employer’s Premises? Yes No 62. Date Employer Notified        63. DESCRIBE WHAT THE EMPLOYEE WAS DOING JUST BEFORE THE INCIDENT AND HOW THE INJURY OCCURRED. ( Ex. While climbing a ladder and carrying roofing materials, ladder slipped on wet floor causing worker to fall 20 feet.)                   PROVIDE DESCRIPTION CODES to identify Nature of Injury , Part of Body that was affected, and Cause of Injury . (FOR COMPLETE LIST OF CODES, GO TO HTTP:// LABOR.ALABAMA.GOV/WC 64. Nature of Injury Code       65. Part of Body Code       66. Cause of Injury Code       67. Initial Treatment No Medical Treatment First Aid By Employer Minor Clinic / Hospital Emergency Room Hospitalized Overnight Hospitalized > 24 Hours Outpatient Treatment 68. Name of Treatment Facility       69. Address       70. City       71. State       72. Zip       73. Name of Physician or Other Health Care Professional   74. Has Injured Returned to Work Yes No If so, 75. Date       76. Time       a.m. p.m. OTHER 77. Date Prepared        78. Preparer’s First Name 79. Last Name 80. Title               81. Preparer’s Telephone Number        03/01/2006