Fill and Sign the Get the 750 Motor Club Ltd Entry Form the Plum Pudding

THE USE OF THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE ALABAMA WORKMEN’S COMPENSATION LAW 03/01/2006 WCC Form 2Rev. 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 ADDRESS10. 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 G GGG 58. State 59. Zip G GGGG 60. County G GGG 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