Wc Form 3 - Supplementary Report

ADVERTISEMENT

MAIL TO: STATE OF ALABAMA
Workers’ Compensation Division
Department of Labor
Montgomery, Alabama 36131
THE USE OF THIS FORM IS REQIRED UNDER THE PROVISIONS OF THE ALABAMA WORKERS' COMPENSATION LAW
SUPPLEMENTARY REPORT
Please type or print
The original of this form must be filed with this office. Copies will not be accepted.
FIRST PAYMENT
REINSTATEMENT
AMENDED
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:
8. Claim #
Service Co #
9. Name, address and telephone number of office filing this report:
Phone:
Ext:
A.
10.
On
the amount of
was paid for the period from
thru
(Date of 1st check)
Average Weekly Wage $
Compensation Rate $
per week.
11.
Type of Disability:
;
;
;
;
;
Temporary Partial
.
Permanent Partial
.
Permanent Total
.
Fatal
.
Temporary Total
12.
If periodic payments are awarded by Circuit Court, give name location and civil action (CV) number and explain:
B.
IF COMPENSATION WAS NOT PAID WITHIN 30 DAYS FROM THE DATE DISABILITY BEGAN, COMPLETE THIS
SECTION.
;
no lost time, (return to work date)
13. Reason for non-payment:
Medical Only
;
Under investigation
reason for prolonged investigation
;
;
In litigation
Under appeal
;
;
14. Has compensation been denied and claimant notified?
Yes
No
Reason?
Date
Signature and Title
Revised 10-12
WC Form 3

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go