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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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