Home Claims Form C Supplemental Claim Form

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.

 

Download the PDF file .

Comments

comments