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Death Benefit Claim Form

Death Benefit Claim Form

 

INSTRUCTIONS: ALABAMA DEATH BENEFIT CLAIM FORM (Form B)

 

 

When an Alabama peace officer or fireman dies, their survivors may seek death benefits from the state by filing a form B death benefit claim form. This document can be obtained from the website of the Alabama Department of Finance. You must print or type all of your answers in ink.

 

Alabama Death Benefit Claim Form B Step 1: Enter your name on the line above the words "Name of Claimant."

 

Alabama Death Benefit Claim Form B Step 2: On line 1, enter your name and mailing address, as well as your home and business telephone numbers.

 

Alabama Death Benefit Claim Form B Step 3: On line 2, give the date of death of the fireman or police officer.

 

Alabama Death Benefit Claim Form B Step 4: On line 3, give the duration of the deceased's employment in that capacity.

 

Alabama Death Benefit Claim Form B Step 5: Line 4 states that you must attach a death certificate as documentation for your claim. You must also include an affidavit from the head of the agency which employed the deceased which states their employment status and provides a description of the circumstances leading to their death.

 

Alabama Death Benefit Claim Form B Step 6: Line 5 requires you to enter all surviving dependents, including spouses, children from a current or previous marriage and parents. Attach additional sheets as necessary. Give the full name and address of every dependent, as well as their relationship to the deceased and their age. Note whether they were receiving support from the deceased.

 

Alabama Death Benefit Claim Form B Step 7: On line 6, give the geographic location of the site of injury or death.

 

Alabama Death Benefit Claim Form B Step 8: On line 7, provide your explanation of the circumstances of death, including the name of the deceased. Attach additional sheets as necessary.

 

Alabama Death Benefit Claim Form B Step 9: If you are represented by an attorney, enter their name, address and telephone number.

 

Alabama Death Benefit Claim Form B Step 10: Sign the form in the presence of a notary public.

 

Alabama Death Benefit Claim Form B Step 11: File the form in duplicate along with all supporting documentary evidence. This must also be submitted in duplicate. 

 

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BC/BS Expense Claim

BC/BS Expense Claim

 

INSTRUCTIONS: BLUE CROSS/BLUE SHIELD OF ALABAMA MEDICAL EXPENSE CLAIM

 

 

Those who are enrolled for medical insurance through Blue Cross/Blue Shield of Alabama should file the medical expense claim discussed in this article when their physician or provider does not file a claim. This form can be found on the website of the Alabama State Employees' Insurance Board, which administers Blue Cross/Blue Shield insurance to state workers.

 

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 1: In box 1, enter the patient's name.

 

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 2: In box 2, enter your contract number as shown on your identification card.

 

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 3: In box 3, enter your group number as shown on your identification card or place of employment.

 

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 4: In box 4, enter the patient's date of birth.

 

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 5: In box 5, indicate the patient's gender with a check mark.

 

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 6: In box 6, indicate the patient's relationship to the contract holder with a check mark. If not the person holding the policy, their spouse or child, explain.

 

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 7: In box 7, give the name, address and telephone number of the contract holder.

 

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 8: In box 8, indicate with a check mark whether the patient is covered under any other group health insurance plan. If so, give the name of the policy holder of that plan, the name and address of the insuring company, the policy identification number and the date on which it became effective.

 

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 9: In box 9, indicate if the patient's condition was related to their employment, an auto accident, or another accident or injury.

 

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 10: In box 10, enter the diagnoses.

 

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 11: In box 11, give the phone number, name and address of the ordering physician. Sign and date the bottom of the form.

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Worker’s Compensation Combination Supplementary and Claim Summary Form

Worker's Compensation Combination Supplementary and Claim Summary Form

 

INSTRUCTIONS: ALABAMA COMBINATION SUPPLEMENTARY & CLAIM SUMMARY FORM

 

 

Alabama businesses use the form discussed in this article to document compensation paid or not paid through workers' compensation insurance for an on-the-job injury. This document can be obtained from the website maintained by the Alabama Department of Labor.

 

Alabama Combination Supplementary & Claim Summary Form Step 1: On line 1, enter the name of the employee.

 

Alabama Combination Supplementary & Claim Summary Form Step 2: On line 2, enter the employee's Social Security number.

 

Alabama Combination Supplementary & Claim Summary Form Step 3: On line 3, enter the name of the employer.

 

Alabama Combination Supplementary & Claim Summary Form Step 4: On line 4, enter the business unemployment compensation number.

 

Alabama Combination Supplementary & Claim Summary Form Step 5: On line 5, enter the date of the injury.

 

Alabama Combination Supplementary & Claim Summary Form Step 6: On line 6, enter the date the disability began this period.

 

Alabama Combination Supplementary & Claim Summary Form Step 7: On line 7, enter the name of your insurance carrier.

 

Alabama Combination Supplementary & Claim Summary Form Step 8: On line 8, enter the claim number.

 

Alabama Combination Supplementary & Claim Summary Form Step 9: On line 9, enter the service company number.

 

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

 

Alabama Combination Supplementary & Claim Summary Form Step 11: The next section of this form contains the supplemental report section. Indicate whether this concerns a first payment, reinstatement or an amended form with a check mark.

 

Alabama Combination Supplementary & Claim Summary Form Step 12: On line 1, give the date of the first check, the amount, the beginning and ending dates of the period it covered, the worker's average weekly wage and their compensation rate.

 

Alabama Combination Supplementary & Claim Summary Form Step 13: Indicate the type of disability on line 2 with a check mark.

 

Alabama Combination Supplementary & Claim Summary Form Step 14: Complete the rest of the section as instructed.

 

Alabama Combination Supplementary & Claim Summary Form Step 15: The next section is the claim summary form. Indicate whether this concerns a suspension, settlement or an amended form with a check mark.

 

Alabama Combination Supplementary & Claim Summary Form Step 16: Complete the rest of the form as instructed and sign where indicated.

 

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