INSTRUCTIONS: ALABAMA DEATH BENEFIT CLAIM FORM (Form B)

As part of the death benefit claim process for survivors of Alabama peace officer or fireman who have had their claim denied, a form B will be filed. This document can be obtained from the website maintained by the Alabama Board of Adjustment.

Alabama Death Benefit Claim Form B Step 1: Enter your name on the first blank line.

Alabama Death Benefit Claim Form B Step 2: On the first three blank lines of line 1, enter your name, mailing address and zip code.

Alabama Death Benefit Claim Form B Step 3: On the next blank line of line 1, enter your home telephone number, including the area code.

Alabama Death Benefit Claim Form B Step 4: On the next blank line of line 1, enter your work telephone number, including the area code.

Alabama Death Benefit Claim Form B Step 5: On line 2, enter the date of death of the peace officer or fireman.

Alabama Death Benefit Claim Form B Step 6: On line 3, enter how long the peace officer or fireman had been employed in that capacity.

Alabama Death Benefit Claim Form B Step 7: Line 4 states that you must attach a death certificate and affidavit from the head of the agency which employed the deceased stating the status of their employment and the circumstances of their death.

Alabama Death Benefit Claim Form B Step 8: In section 5, you must document all surviving dependents in the table provided. In the first column, enter the full name and address of each dependent.

Alabama Death Benefit Claim Form B Step 9: In the second column, enter each dependent's relationship to the deceased.

Alabama Death Benefit Claim Form B Step 10: In the third column, enter each dependent's age.

Alabama Death Benefit Claim Form B Step 11: In the fourth column, indicate whether the deceased was contributing to support each listed dependent.

Alabama Death Benefit Claim Form B Step 12: On line 6, enter the geographic location of the injury or death.

Alabama Death Benefit Claim Form B Step 13: On line 7, state in your own words the circumstances related to the death of the peace officer or fireman.

Alabama Death Benefit Claim Form B Step 14: Sign the form where indicated, then have it certified by a notary public.

INSTRUCTIONS: ALABAMA DEATH BENEFIT CLAIMS EXAMPLES OF SUPPORTING DOCUMENTATION

This article discusses an information document outlining acceptable supporting documentation for support claims due to the death of an Alabama peace officer or fireman. This document can be obtained from the website maintained by the Alabama State Board of Adjustment.

Alabama Death Benefit Claims Examples Of Supporting Documentation Step 1: The first listed acceptable supporting document is a death certificate for the deceased Alabama peace officer or fireman.

Alabama Death Benefit Claims Examples Of Supporting Documentation Step 2: The second listed acceptable supporting document is an accident or incident report, if applicable.

Alabama Death Benefit Claims Examples Of Supporting Documentation Step 3: The third listed acceptable support document is an affidavit from the head of the employing agency or department which must answer several questions about the death of the peace officer or fireman. The first question which must be addressed in this affidavit is if the peace officer or fireman was engaged in the performance of their duties when killed or receiving injuries contributing to their death.

Alabama Death Benefit Claims Examples Of Supporting Documentation Step 4: The second question to be answered in this affidavit is if the peace officer or fireman was engaged in willful misconduct.

Alabama Death Benefit Claims Examples Of Supporting Documentation Step 5: The third question to be answered is if the peace officer or fireman was intoxicated by alcohol or drugs at the time of death and whether tests were conducted with regard to alcohol or drugs.

Alabama Death Benefit Claims Examples Of Supporting Documentation Step 6: The fourth question to be answered is if the peace officer or fireman failed to use safety appliances supplied by their employer.

Alabama Death Benefit Claims Examples Of Supporting Documentation Step 7: The fifth question to be answered is if the peace officer or fireman refused or neglected to perform a statutory duty.

Alabama Death Benefit Claims Examples Of Supporting Documentation Step 8: The sixth question to be answered is if the peace officer or fireman violated a law or willfully breached a reasonable rule or regulation governing the performance of their duties or employment.

Alabama Death Benefit Claims Examples Of Supporting Documentation Step 9: The rest of the form identifies documents acceptable for identifying surviving dependents. 

INSTRUCTIONS: CONNECTICUT PROOF OF CLAIM (SURETY LIQUIDATION)

This article discusses a proof of claim form that was made available following the liquidation of the Connecticut Surety Corporation and related affiliates. This form was made available to file a claim against these businesses. Though the deadline to file this form was August 29, 2003, the form can still be found on the website of the government of Connecticut.

Connecticut Proof Of Claim (Surety Liquidation) Step 1: Enter the claimant name in the first blank box.

Connecticut Proof Of Claim (Surety Liquidation) Step 2: Enter the claimant address in the second blank box.

Connecticut Proof Of Claim (Surety Liquidation) Step 3: Enter the claimant telephone number in the third blank box.

Connecticut Proof Of Claim (Surety Liquidation) Step 4: Enter the claimant Social Security number or tax identification number in the fourth blank box.

Connecticut Proof Of Claim (Surety Liquidation) Step 5: Enter the total amount of the claim in the fifth blank box.

Connecticut Proof Of Claim (Surety Liquidation) Step 6: If any affiliates paid any portion of your claim, enter the name of the affiliate in the sixth blank box and the date of payment and the amount of payment made in the seventh blank box.

Connecticut Proof Of Claim (Surety Liquidation) Step 7: If you hold any security or collateral provided by the affiliates or claim a right of setoff against any of the affiliates, enter the name of the affiliates in question in the eighth blank box and the amount held or subject to set setoff in the ninth blank box.

Connecticut Proof Of Claim (Surety Liquidation) Step 8: If you assert any right of priority senior to the right of general creditors, identify the priority asserted and the basis for this assertion in the tenth blank box.

Connecticut Proof Of Claim (Surety Liquidation) Step 9: If you are represented by an attorney, enter their name in the eleventh blank box, their address in the twelfth blank box, and their telephone number in the thirteen blank box.

Connecticut Proof Of Claim (Surety Liquidation) Step 10: The claimant or individual, partner, officer or legal representative of the claimant should provide their signature, the date, their title or official capacity and telephone number where indicated. 

Connecticut Proof Of Claim (Surety Liquidation) Step 11: A notary public should be presented with the form to affix their seal.

INSTRUCTIONS: ALABAMA SOUTHLAND BENEFIT SOLUTIONS EMPLOYEE'S STATEMENT

Alabama state employees enrolled in medical coverage administered by Southland Benefit Solutions can use the form discussed in this article to file a claim for a hospital bill. This document can be obtained from the website maintained by Southland Benefit Solutions.

Alabama Southland Benefit Solutions Employee's Statement Step 1: Enter the subscriber's name in box 1.

Alabama Southland Benefit Solutions Employee's Statement Step 2: Enter the subscriber's contract number in box 2.

Alabama Southland Benefit Solutions Employee's Statement Step 3: Enter the subscriber's home address in box 3.

Alabama Southland Benefit Solutions Employee's Statement Step 4: Enter the patient's name in box 4.

Alabama Southland Benefit Solutions Employee's Statement Step 5: Enter the patient's date of birth in box 5.

Alabama Southland Benefit Solutions Employee's Statement Step 6: Enter the patient's age in box 6.

Alabama Southland Benefit Solutions Employee's Statement Step 7: Indicate the patient's sex with a check mark in box 7.

Alabama Southland Benefit Solutions Employee's Statement Step 8: Indicate the patient's relationship to the subscriber with a check mark in box 8.

Alabama Southland Benefit Solutions Employee's Statement Step 9: Enter the subscriber's home and work phone number in box 9.

Alabama Southland Benefit Solutions Employee's Statement Step 10: In box 10, enter the type of illness or injury or the doctor's diagnosis.

Alabama Southland Benefit Solutions Employee's Statement Step 11: In the next blank box, enter the physician's name and address.

Alabama Southland Benefit Solutions Employee's Statement Step 12: In the next blank box, enter the name of the hospital, if confined.

Alabama Southland Benefit Solutions Employee's Statement Step 13: In the next blank box, enter the date you were admitted.

Alabama Southland Benefit Solutions Employee's Statement Step 14: In the next blank box, enter the date you were discharged.

Alabama Southland Benefit Solutions Employee's Statement Step 15: In the next blank box, enter the date the accident or sickness began.

Alabama Southland Benefit Solutions Employee's Statement Step 16: In the next blank box, enter the date the accident or sickness was first treated.

Alabama Southland Benefit Solutions Employee's Statement Step 17: In the next blank box, indicate whether the condition was related to accident or illness.

Alabama Southland Benefit Solutions Employee's Statement Step 18: Sign and date the form where indicated.

INSTRUCTIONS: ALABAMA COMBINATION SUPPLEMENTARY & CLAIM SUMMARY FORM 

When an Alabama company pays workers compensation to an employee injured or involved in an accident on the job, they can file a combination supplementary and claim summary form documenting payments made. This form can be found on the website of the Alabama Department of Labor.

Alabama Combination Supplementary & Claim Summary Form Step 1: The first section must be completed by all filing it. Enter the name of the employee on line 1 and their Social Security number on line 2.

Alabama Combination Supplementary & Claim Summary Form Step 2: Enter the employer name on line 3 and your unemployment compensation number on line 4.

Alabama Combination Supplementary & Claim Summary Form Step 3: Enter the date of the injury on line 5 and the date the disability began this period on line 6.

Alabama Combination Supplementary & Claim Summary Form Step 4: Enter the name of the insurance carrier on line 7, the claim number on line 8, and the service company number on line 9.

Alabama Combination Supplementary & Claim Summary Form Step 5: On line 10, enter the name, address and telephone number of the officer filing this report.

Alabama Combination Supplementary & Claim Summary Form Step 6: The next section is the Supplemental Report. Indicate with a check mark if this documents a first payment or a reinstatement or is an amended return.

Alabama Combination Supplementary & Claim Summary Form Step 7: Complete section A if you have made payment. Enter the amount and period of payment on line 1 and indicate the type of disability with a check mark on line 2. If periodic payments were awarded by a circuit court, give its name and location and the civil action number on line 3.

Alabama Combination Supplementary & Claim Summary Form Step 8: If compensation was not paid within 30 days from the onset of the disability, complete section B.

Alabama Combination Supplementary & Claim Summary Form Step 9: The next section is the Claim Summary Form. Indicate with a check mark if you are filing a form documenting a suspension or settlement or an amended form.

Alabama Combination Supplementary & Claim Summary Form Step 10: Answer all questions on lines 1 through 5.

Alabama Combination Supplementary & Claim Summary Form Step 11: Provide the date, the adjuster name and title and your signature at the bottom of the page.

INSTRUCTIONS: ALABAMA SOUTHLAND BENEFIT SOLUTIONS VISION CLAIM FORM

Alabama public employees enrolled in the state's vision care administered through Southland Benefit Solutions use the form discussed in this article to file a claim for vision care. This document can be obtained from the website maintained by Southland Benefit Solutions.

Alabama Southland Benefit Solutions Vision Claim Form Step 1: In box 1, indicate whether you are enrolled in Medicare, Medicaid, a group health plan or another plan with a check mark.

Alabama Southland Benefit Solutions Vision Claim Form Step 2: In box 1a, enter the insured's ID number.

Alabama Southland Benefit Solutions Vision Claim Form Step 3: In box 2, enter the patient's name.

Alabama Southland Benefit Solutions Vision Claim Form Step 4: In box 3, enter the patient's date of birth and indicate their gender with a check mark.

Alabama Southland Benefit Solutions Vision Claim Form Step 5: In box 4, enter the insured's name.

Alabama Southland Benefit Solutions Vision Claim Form Step 6: In box 5, enter the patient's address.

Alabama Southland Benefit Solutions Vision Claim Form Step 7: In box 6, indicate the patient's relationship to the insured with a check mark.

Alabama Southland Benefit Solutions Vision Claim Form Step 8: In box 7, enter the insured's address.

Alabama Southland Benefit Solutions Vision Claim Form Step 9: In box 8, indicate the patient's marital and employment status with a check mark.

Alabama Southland Benefit Solutions Vision Claim Form Step 10: In box 9, enter the name of any other insured party. 

Alabama Southland Benefit Solutions Vision Claim Form Step 11: In box 9a, enter the policy or group number of the other insured party. In box 9b, enter their date of birth and indicate their gender with a check mark. Enter their employer or school name in box 9c and their insurance plan name or program name in box 9d,

Alabama Southland Benefit Solutions Vision Claim Form Step 12: In box 10, enter the insured's policy group or FECA number. In box 10a, enter the insured's date of birth and indicate their gender with a check mark. Enter their employer or school name in box 10b, their insurance plan name or program name in box 10c and indicate whether there is another health benefit plan in box 10d with a check mark. Complete the rest of the form as instructed.