Free WC First Report of Injury (WC Form 2 9/2006) - Alabama

THE USE OF THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE ALABAMA WORKERS'S COMPENSATION LAW

WCC Form 2 Rev. 9/2006

STATE OF ALABAMA

EMPLOYER'S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE Ombudsman 1-800-528-5166 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 15. Federal ID Number 18. Insurer Name 19. Insurer Federal ID Number 20. Type Insurer Insurance Co. Self-Insurer Group Fund ADDRESS, IF LOCATION DIFFERENT FROM BUSINESS ADDRESS 10. Mailing Address 1 11. Mailing Address 2 or Telephone Number 12. City 13. State 14. Zip 16. U.C. Account Number 17. NAICS

INSURER / FILING OFFICE
21. Filing Office Name 21a. Service Co. # 22. Mailing Address 1 23. Mailing Address 2 or Telephone Number 24. City 25. State 26. Zip 27. Filing Office Federal ID Number

Ins Co # SI # GF #

EMPLOYEE / WAGES
28. First Name 29. Middle Name 30. Last Name 31 Last Name Suffix (ie. Jr., Sr., III) 34. Mailing Address 1 35. Mailing Address 2 36. City 37. State 38. Zip 39. Phone 43. Marital Status Unmarried (Single or Divorced or Widowed) 45. Occupation Description 47. Wages $ 48. Hourly Daily Weekly Bi-weekly 51. Date of Injury 52. Time of Injury
a.m. p.m. unk

32. Employee ID Number 33. Type Employee ID Number Passport Number Green Card SSN Employment Visa Assigned by Jurisdiction 40. Gender Male Female Married Separated Unknown 41. Date of Birth 42.Nbr of Dependents 44. Date Hired

Monthly

46. Number of Days Worked Per Week 49. Received Full Pay For Day of Injury? Yes No 50. Did Salary Continue? Yes No 54. Date Disability Began 55. Date of Death

INJURY / TREATMENT
53. Time Employee Began Work
a.m. p.m.

PLACE OF ACCIDENT, INJURY, OR EXPOSURE 56. Site Address

61. Injury Occurred on Employer's Premises? No Yes

62. Date Employer Notified 58. State 59. Zip 60. County 57. City 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:// DIR.ALABAMA.GOV/WC

64. Nature of Injury Code 65. Part of Body Code 66. Cause of Injury Code 67. Initial Treatment 68. Name of Treatment Facility No Medical Treatment First Aid By Employer Emergency Room Minor Clinic / Hospital 69. Address Hospitalized > 24 Hours Major medical/Lost time 70. City 71. State 72. Zip Hospitalized Overnight 73. Name of Physician or Other Health Care Professional 74. Has Injured Returned to Work If so, 75. Date Yes No 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

03/01/2006