Home Claims

Claims

WC Supplementary Report WC Form 3

WC Supplementary Report WC Form 3

 

INSTRUCTIONS: ALABAMA SUPPLEMENTARY REPORT (WC Form 3)

 

 

Alabama employers are required to file a WC Form 3 whenever payment is made to a worker injured on the job. This document can be found on the website of the Alabama Department of Labor.

 

Alabama Supplementary Report WC 3 Step 1: Indicate with a check mark if this report documents a first payment, a reinstatement, or is an amended report.

 

Alabama Supplementary Report WC 3 Step 2: On line 1, enter the name of the employee. On line 2, enter their Social Security number.

 

Alabama Supplementary Report WC 3 Step 3: On line 3, enter the name of the employer. On line 4, enter their unemployment compensation number.

 

Alabama Supplementary Report WC 3 Step 4: On line 5, enter the date on which the injury occurred.

 

Alabama Supplementary Report WC 3 Step 5: On line 6, enter the date in this period on which the disability began.

 

Alabama Supplementary Report WC 3 Step 6: On line 7, enter the name of your insurance carrier. 

 

Alabama Supplementary Report WC 3 Step 7: On line 8, enter your claim and service company numbers.

 

Alabama Supplementary Report WC 3 Step 8: On line 9, provide the name, address and telephone number of the officer completing this report.

 

Alabama Supplementary Report WC 3 Step 9: On line 10, enter the date on which the first check was cut, the amount, and the dates for which it was paid. Also enter the worker's average weekly wage and compensation rate per week.

 

Alabama Supplementary Report WC 3 Step 10: On line 11, indicate with a check mark if the disability was temporary total, temporary partial, permanent partial, permanent total, or if the incident resulted in a fatality.

 

Alabama Supplementary Report WC 3 Step 11: If periodic payments were awarded by a circuit court, enter its name and location and the civil action number on line 12.

 

Alabama Supplementary Report WC 3 Step 12: If payment was not made within 30 days from the date the disability began, explain why on line 13.

 

Alabama Supplementary Report WC 3 Step 13: If compensation was denied and the claimant was notified, note this on line 14 and explain why.

 

Alabama Supplementary Report WC 3 Step 14: Sign and date the form, as well as providing your title.

Download the PDF file .

Southland Dental Claim

Southland Dental Claim

 

INSTRUCTIONS: SOUTHLAND DENTAL CLAIM FORM 

 

 

Alabama public employees are enrolled with Southland Benefit Solutions for their health insurance. Those needing to make a claim for reimbursement for dental treatment should file the form discussed in this article, which is found on the website of the Retirement Systems of Alabama.

 

Southland Dental Claim Form Step 1: In box 1, indicate with check marks what type of transaction this form documents. In box 2, enter your predetermination or preauthorization number. In box 3, enter the name of your insurance company or dental benefit plan and its address.

 

Southland Dental Claim Form Step 2: Box 4 asks you to indicate with a check mark if you have other dental or medical coverage. If you check "No," skip to box 12. If you check "Yes," you must complete boxes 5 through 11.

 

Southland Dental Claim Form Step 3: In box 5, give the name of the policyholder of the other insurance or dental benefits plan. In box 6 give their age, indicate their gender in box 7, give their subscription identification number in box 8, and their plan or group number in box 9. Indicate the patient's relationship to the policyholder with a check mark in box 10. Give the name of the plan and its address in box 11.

 

Southland Dental Claim Form Step 4: In box 12, enter the name of the policyholder or subscriber to the dental or medical insurance plan for which you are submitting a claim. In box 13 give their date of birth and indicate their gender with a check mark in box 14. Enter their subscription identification number in box 15, their plan or group number in box 16, and their employer's name in box 17.

 

Southland Dental Claim Form Step 5: In box 18, indicate with a check mark if the patient is the policy holder or their spouse or child. If you are a student, indicate whether you are part or full time in box 19. In box 20, give the patient's name and address. In box 21, give their date of birth. In box 22, indicate their gender with a check mark. In box 23, give the patient's identification or account number. 

 

Southland Dental Claim Form Step 6: Sections 24 through 33 document all services provided. Boxes 34 and 35 concern missing teeth. The patient and dentist should complete all sections below.

Download the PDF file .

Form A Claim Form

Form A Claim Form

 

INSTRUCTIONS: ALABAMA CLAIM FORM (Form A)

 

 

Alabama public employees can use a form A as part of the claims process related to an on-the-job accident or injury. This documentary can be obtained from the website maintained by the Alabama State Board of Adjustment.

 

Alabama Claim Form A Step 1: If this is a supplemental claim form, enter the original claim number and the department or agency it concerns.

 

Alabama Claim Form A Step 2: On the first two blank lines of section 1, enter the name and mailing address of the claimant.

 

Alabama Claim Form A Step 3: On the next blank line of section 1, enter the claimant's home telephone number.

 

Alabama Claim Form A Step 4: On the next blank line, enter the claimant's work phone number.

 

Alabama Claim Form A Step 5: On the next blank line, enter the claimant's Social Security number or federal ID number.

 

Alabama Claim Form A Step 6: If the injured party is under 19 years of age, the claim must be filed and signed by the parent or guardian. If this is the case, on the next blank line enter the name and age of the minor and the name and relationship to them of the person acting as claimant.

 

Alabama Claim Form A Step 7: On the first blank line of section 2, enter the name of the claimant's attorney if applicable. In the rest of the section, enter their mailing address, zip code and telephone number.

 

Alabama Claim Form A Step 8: In section 3, enter the date of the accident or injury.

 

Alabama Claim Form A Step 9: In section 4, if this claim does not concern an accident or injury, enter the date on which the claim arose.

 

Alabama Claim Form A Step 10: In section 5, enter the location where the injury or damage occurred.

 

Alabama Claim Form A Step 11: Section 6 requires you to give a statement of the facts in your own words.

 

Alabama Claim Form A Step 12: Section 7 requires you to indicate what the claim is made for.

 

Alabama Claim Form A Step 13: Section 8 concerns damages to personal property.

 

Alabama Claim Form A Step 14: Section 9 concerns miscellaneous or other expenses.

 

Alabama Claim Form A Step 15: Enter the total amount claimed in section 10 and other payments made in section 11. Sign section 12.

 

Download the PDF file .

Southland Vision Claim

Southland Vision Claim

 

INSTRUCTIONS: SOUTHLAND VISION CLAIM FORM 

 

 

Alabama public employees file the form discussed in this article to obtain reimbursement for vision treatment. This form is processed by Southland Benefit Solutions, which manages health care for the state of Alabama. The document can be found on the website of the Retirement Systems of Alabama.

 

Southland Vision Claim Form Step 1: In box 1, indicate the type of coverage you have with a check mark. In box 1a, enter your insurance identification number.

 

Southland Vision Claim Form Step 2: Enter the patient name in box 2, their birth date and gender in box 3, and the last name of the insured in box 4.

 

Southland Vision Claim Form Step 3: Enter the patient's address in box 5, indicate the patient's relationship to the insured in box 6, and give the insured's address in box 7.

 

Southland Vision Claim Form Step 4: In box 8, indicate with the check marks whether the patient is single, married or other, as well as whether the patient is employed, or a part-time or full-time patient.

 

Southland Vision Claim Form Step 5: Skip to box 10 and enter the insured's policy group or FECA number. Enter the insured's date of birth in box 10a, their employer or school name in box 10b and their insurance plan or program name in box 10c. If you have another health benefit plan, return to boxes 9 through 9d and complete them.

 

Southland Vision Claim Form Step 6: Enter the insured's name in box 9, their policy or group number in box 9a, their date of birth and gender in box 9b, their employer or school name in box 9c, and their insurance plan or program name in box 9d.

 

Southland Vision Claim Form Step 7: The patient or an authorized person should sign and date box 11.

 

Southland Vision Claim Form Step 8: The insured or an authorized person should sign box 12.

 

Southland Vision Claim Form Step 9: The remainder of the form should be completed by the supervising physician. Your vision prescriptions will be entered, along with a diagnosis of your illness or injury, a detailed itemization of all services provided, and identifying information about the doctor and their place of business. The physician should sign and date the bottom of the document.

 

Download the PDF file .

Form C Supplemental Claim Form

Form C Supplemental Claim Form

 

INSTRUCTIONS: ALABAMA SUPPLEMENTAL CLAIM (Form C)

 

 

The form discussed in this article is used to file a claim for expenses not paid by an Alabama public department or agency. This document can be obtained from the website of the Alabama State Board of Adjustment. 

 

Alabama Supplemental Claim C Step 1: If this form is a supplement to a previously filed claim, enter the claim number and agency name where indicated.

 

Alabama Supplemental Claim C Step 2: Section 1 concerns the claimant. On the first two blank lines, enter the name and mailing address of the claimant.

 

Alabama Supplemental Claim C Step 3: On the third blank line, enter your home phone number, including the area code.

 

Alabama Supplemental Claim C Step 4: On the fourth blank line, enter your business phone number, including the area code.

 

Alabama Supplemental Claim C Step 5: On the fifth blank line, enter your Social Security number or federal ID number.

 

Alabama Supplemental Claim C Step 6: If the injured party is 19 years of age or younger, their parent or guardian must file the form as the claimant. If this is the case, enter the name and age of the minor on the sixth blank line and the name and relationship of the person with whom the minor lives.

 

Alabama Supplemental Claim C Step 7: Section 2 concerns the claimant's attorney, if applicable. Enter the attorney's name on the first blank line, their mailing address on the second blank line, and their zip code and telephone number on the last two blank lines.

 

Alabama Supplemental Claim C Step 8: In section 3A, indicate whether this is a claim for uninsured medical expenses with a check mark. If so, enter the amount. Indicate whether you have insurance with a check mark. If so, enter the name of the company.

 

Alabama Supplemental Claim C Step 9: In section 3B, indicate whether this claim concerns a permanent disability with a check mark. If so, provide all information requested.

 

Alabama Supplemental Claim C Step 10: In section 3C, indicate whether this claim concerns lost wages or compensation for leave used with a check mark. If so, provide all information requested. In section 3D, indicate whether this claim concerns miscellaneous or other expenses with a check mark. If so, provide all information requested. Sign the form and have it certified by a notary public.

 

Download the PDF file .