Alabama Claims Summary Form

STATE OF ALABAMA
Workers' Compensation Division
Department of Labor
Montgomery, Alabama 36131
Mail to:
The original of this form must be filed with this office. Copies will not be accepted.
The use of this form is required under the provisions of the Alabama Workers' Compensation Law.
CLAIMS SUMMARY FORM
PLEASE TYPE OR PRINT
SUSPENSION
SETTLEMENT
AMENDED
1. Employee:
2. S.S.N.
3. Employer:
4. Unemployment Compensation #
6.
5. Date of Injury:
Date disability began this period
7. Insurance carrier:
8. Claim #
9. Service Co #
10. Name, address and telephone number of office filing this report:
Phone:
Ext:
(DO NOT INCLUDE ANY PAYMENTS PREVIOUSLY FILED ON A CLAIM SUMMARY FORM)
11. Date last day comp paid
RTW
12. Did claimant work during this period of disability?
13. AWW
YES
MMI
NO
If so, from
14. Medical pd this period
CR (66.67%)
15. Amount and type of comp paid:
TTD $
WKS
Days
TPD $
WKS
PPD $
WKS
Days
PTD $
WKS
Days
Death $
WKS
Days
%
Estate Pmt $
Burial Payment $
Future Med $
LSP $
Date Pd
WKS
%
Days
Part of Body
16. Ombudsman
17. Legal:
POB
Yes
Pltf Fees $
Date
WC 4 Revised 10-12
No
Location (County)
Court CV#
Exp $
Def Fees $
Signature and Title
Exp $