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.
Alabama Claims Summary Form WC 4 Step 14: On line 13, enter the average weekly wage (AWW) and compensation rate.
Alabama Claims Summary Form WC 4 Step 15: Complete lines 14 through 17 as directed to document all other payments and fees disbursed.
Alabama Claims Summary Form WC 4 Step 16: Sign and date the form and give your title.