Fill and Sign the Combination Supplementary and Claim Summary Formpdf

10/01/2012 MAIL TO: STATE OF ALABAMAWorkers’ 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 PAYMENTREINSTATEMENT AMENDED A.1.On the amount of $ was paid for the period from thru (Date of 1st 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) numberand 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 SUSPENSIONSETTLEMENTAMENDED (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