Free WC - COMBINATION SUPPLEMENTARY & CLAIM SUMMARY FORM - Alabama


File Size: 16.8 kB
Pages: 1
Date: December 27, 2006
File Format: PDF
State: Alabama
Category: Workers Compensation
Author: jm
Word Count: 272 Words, 1,818 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dir.alabama.gov/docs/forms/wc_combination%20_rev%201-16-02_-1.pdf

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MAIL TO: STATE OF ALABAMA Workers' Compensation Division Department of Industrial Relations Montgomery, Alabama 36131 1(800)528-5166, fax (334)353-0840 E-Mail: [email protected]

COMBINATION SUPPLEMENTARY & CLAIM SUMMARY FORM
1. Employee: 3. Employer: 5. Date of Injury: 7. Insurance carrier: 10. Name, address and telephone number of office filing this report: 2. Social Security number: 4. Unemployment Compensation Number: 6. Date disability began this period: 8. Claim # 9. Service Co #

SUPPLEMENTAL REPORT FIRST PAYMENT REINSTATEMENT
the amount of
(Date of 1st check)

AMENDED
thru per week. ; Permanent Total ; Fatal

A.
1. On $ was paid for the period from Compensation Rate ; $ Average Weekly Wage 2. 3. Type of Disability: Temporary Total ; $ Temporary Partial

Permanent Partial

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) Under investigation , reason for prolonged investigation In litigation , Under appeal Has compensation been denied and claimant notified? Yes

5.

No

Reason ?

CLAIM SUMMARY FORM SUSPENSION
1. 2. 3. 4. Last day comp was owed and paid
Did claimant work during this period of disability? Yes No

SETTLEMENT
RTW
If so, from

AMENDED
MMI
to total days

(DO NOT INCLUDE ANY PAYMENTS PREVIOUSLY FILED ON A CLAIM SUMMARY FORM)

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 Ombudsman Yes Date No Court CV# Adjuster & Title Signature

Days Days Days Days $ % POB

WKS Location (County)

Days

5.

02/15/2001