Alabama Combination Supplementary And Claim Summary 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:
10. Name, address and telephone number of office filing this report:
8. Claim #
9. Service Co #
SUPPLEMENTAL REPORT
FIRST PAYMENT
REINSTATEMENT
AMENDED
A.
1.
On
the amount of
$
was paid for the period from
thru
(Date of 1st check)
Average Weekly Wage
2.
3.
Type of Disability:
Temporary Total ;
$
Compensation Rate
Temporary Partial
;
$
Permanent Partial
per week.
;
Permanent Total
;
Fatal
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)
5.
Under investigation , reason for prolonged investigation
In litigation , Under appeal
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.
2.
Last day comp was owed and paid
3.
4.
AWW
$
CR (66.7%)
$
Amount and type of comp paid:
TTD
$
WKS
TPD
$
WKS
PPD
$
WKS
PTD
$
WKS
Death
$
WKS
Estate Payment
$
Burial Payment
LSP
$
Date Pd
%
Part of Body
5.
RTW
Did claimant work during this period of disability?
Ombudsman Yes
Date
No
Yes
No
Court CV#
MMI
If so, from
total days
to
Days
Days
Days
Days
$
%
POB
WKS
Days
Location (County)
Adjuster & Title
Signature
10/01/2012