WC Claim Summary Form WC 4

INSTRUCTIONS: ALABAMA CLAIMS SUMMARY FORM (Form WC 4)

When an Alabama employee is injured on the job, their employer is required to provide workers compensation coverage for treatment. The insurance company is required to submit a form WC 3 or WC 4 showing money paid to the worker. The form is found on the website of the Alabama Department of Labor.

Alabama Claims Summary Form WC 4 Step 1: Indicate with a check mark if this form documents a suspension, settlement or an amended form.

Alabama Claims Summary Form WC 4 Step 2: On line 1, enter the employee's name.

Alabama Claims Summary Form WC 4 Step 3: On line 2, enter the employee's Social Security number.

Alabama Claims Summary Form WC 4 Step 4: On line 3, enter the employer's name.

Alabama Claims Summary Form WC 4 Step 5: On line 4, enter the employer's unemployment compensation number.

Alabama Claims Summary Form WC 4 Step 6: On line 5, enter the date of the injury.

Alabama Claims Summary Form WC 4 Step 7: On line 6, enter the date the disability began in this period.

Alabama Claims Summary Form WC 4 Step 8: On line 7, enter the name of the insurance carrier.

Alabama Claims Summary Form WC 4 Step 9: On line 8, enter the claim number.

Alabama Claims Summary Form WC 4 Step 10: On line 9, enter the service company number.

Alabama Claims Summary Form WC 4 Step 11: On line 10, enter the name, address and telephone number of the insurance officer filing this form.

Alabama Claims Summary Form WC 4 Step 12: Fees paid are documented on lines 11 through 17. Do not include payments documented on a previously filed claims summary form. On line 11, enter the date the last compensation payment was made.

Alabama Claims Summary Form WC 4 Step 13: On line 12, indicate whether the claimant worked during this disability period. If so, give the dates of their work.

Form CL-438 Medical Expense Claim

INSTRUCTIONS: ALABAMA MEDICAL EXPENSE CLAIM (Form CL-438)

Alabama public employees enrolled in a program administered by BlueCross BlueShield use form CL-348 to file a medical expense claim. This document can be obtained from the website maintained by BlueCross BlueShield of Alabama.

Alabama Medical Expense Claim CL-438 Step 1: In box 1, enter the patient's last name, first name and middle initial.

Alabama Medical Expense Claim CL-438 Step 2: In box 2, enter your contract number as it appears on your ID card. If applicable, include any letters.

Alabama Medical Expense Claim CL-438 Step 3: In box 3, enter your group number as it appears on your ID card or your place of employment.

Alabama Medical Expense Claim CL-438 Step 4: In box 4, enter the patient's date of birth.

Alabama Medical Expense Claim CL-438 Step 5: In box 5, indicate the patient's gender by checking "Male" or "Female" as applicable.

Alabama Medical Expense Claim CL-438 Step 6: In box 6, indicate the patient's relationship to the contract holder by checking "Self," "Child," "Spouse" or "Other" as applicable. If the latter, provide an explanation.

Alabama Medical Expense Claim CL-438 Step 7: On the first line of box 7, enter the contract holder's last name, first name and middle initial.

Alabama Medical Expense Claim CL-438 Step 8: On the second line of box 7, enter the contract holder's street address.

Alabama Medical Expense Claim CL-438 Step 9: On the third line of box 7, enter the contract holder's city, state, zip code and daytime telephone number, including any extension if applicable.

Alabama Medical Expense Claim CL-438 Step 10: In section 8, indicate whether the patient is covered under any other group health insurance plan with a check mark. If yes, enter the name of the policy holder on the first blank line, the name and address of the insuring company on the second blank line and the I.D. number on the third blank line. Answer all questions in this section concerning Medicare eligibility as instructed.

Alabama Medical Expense Claim CL-438 Step 11: Section 9 concerns the cause of the condition. Answer lines 9a through 9c by checking any applicable statements.

Alabama Medical Expense Claim CL-438 Step 12: Enter the diagnoses in Section 10.

Alabama Medical Expense Claim CL-438 Step 13: Enter the name, telephone number of the ordering physician in Section 11. Sign and date the bottom of the page.

Order Committing Juvenile to Family Independence Agency

Doctor’s Report of Treatment

WC Notice of Cancellation Form WC

INSTRUCTIONS: ALABAMA NOTICE OF CANCELLATION (WC Form 9)

Alabama businesses which are cancelling their workers compensation account should file a WC Form 9. This document can be obtained from the website of the Alabama Department of Labor, on the section housing all documents related to workers compensation. To initiate this account, you must file a WC Form 7, which is a notice of coverage. This is also filed with and processed by the Alabama Department of Labor.

Alabama Notice Of Cancellation WC 9 Step 1: On the first line, enter your state unemployment compensation tax number.

Alabama Notice Of Cancellation WC 9 Step 2: On the second line, enter your federal identification number.

Alabama Notice Of Cancellation WC 9 Step 3: On the third line, give your corporation or limited liability company name.

Alabama Notice Of Cancellation WC 9 Step 4: On the fourth line, give your trade ("doing business as") name.

Alabama Notice Of Cancellation WC 9 Step 5: On the fifth line, enter your street address, city, state and zip code.

Alabama Notice Of Cancellation WC 9 Step 6: On the sixth line, enter additional locations covered by this form.

Alabama Notice Of Cancellation WC 9 Step 7: On the seventh line, enter the nature of your business.

Alabama Notice Of Cancellation WC 9 Step 8: On the eight line, give your North American Industry Classification System (NAICS) number. This is the code classifying the type of operations your business performs. If you are unaware of what your NAICS number is, a complete list of the codes is available on the website of the Alabama Department of Labor. These codes can also be found the website of the United States Census Bureau.

Alabama Notice Of Cancellation WC 9 Step 9: On the ninth line, enter the date of cancellation.

CT Surety Liquidation Bond Loss Claims Form

INSTRUCTIONS: PROOF OF CLAIM SURETY BOND CLAIM FORM (BOND LOSS CLAIM) THE CONNECTICUT SURETY COMPANY IN LIQUIDATION

Following the liquidation of the Connecticut Surety Company, those affect had until November 15, 2002 to file a claim concerning bond losses. Though this deadline has passed, the form can still be obtained from the website of the government of Connecticut.

Proof Of Claim Surety Bond Claim Form (Bond Loss Claim) The Connecticut Surety Company In Liquidation Step 1: Section I concerns the bond. Enter the bond principal on the first blank line, the bond obligee on the next blank line, the bond type on the next blank line, the bond number on the next blank line, the bond effective date on the next blank line, the bond end date on the next blank line, and (if applicable) the project name on the last blank line of this section.

Proof Of Claim Surety Bond Claim Form (Bond Loss Claim) The Connecticut Surety Company In Liquidation Step 2: On line 1, enter the claimant's full name.

Proof Of Claim Surety Bond Claim Form (Bond Loss Claim) The Connecticut Surety Company In Liquidation Step 3: On line 2, enter the claimant's mailing address.

Proof Of Claim Surety Bond Claim Form (Bond Loss Claim) The Connecticut Surety Company In Liquidation Step 4: On line 3, enter the claimant's home and business telephone numbers.

Proof Of Claim Surety Bond Claim Form (Bond Loss Claim) The Connecticut Surety Company In Liquidation Step 5: On line 4, indicate what the claim is for by circling the letter of the applicable statement.

Proof Of Claim Surety Bond Claim Form (Bond Loss Claim) The Connecticut Surety Company In Liquidation Step 6: On line 5, give a concise explanation of the particulars of your claim.

Proof Of Claim Surety Bond Claim Form (Bond Loss Claim) The Connecticut Surety Company In Liquidation Step 7: On line 6, enter the amount to which the Connecticut Surety Company was indebted at the time the order of liquidation was entered on May 17, 2002.

Proof Of Claim Surety Bond Claim Form (Bond Loss Claim) The Connecticut Surety Company In Liquidation Step 8: Indicate what supporting documentation is attached on line 7.

Proof Of Claim Surety Bond Claim Form (Bond Loss Claim) The Connecticut Surety Company In Liquidation Step 9: Complete the remainder of the form as directed.

Claims

Order for Writ of Possession (Claim and Delivery)

Notice for Injured Workers’ to Access Diagnostic Services

Motion/Order of Nolle Prosequi

Claim Kit for self-insured trust members