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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.

 

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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.

 

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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.

 

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Form B Death Benefit Claim Form

Form B Death Benefit Claim Form

 

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.

 

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