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Supplemental Claim Form

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Supplemental Claim Form





To file a claim with the state of Alabama for supplemental expenses following an accident, you must do so within a year of the incident, or within two if the accident resulted in death. The form can be found on the website of the Alabama Board of Adjustment.


Alabama Supplemental Claim C Step 1: If this is a supplement to a previously filed claim, give the claim number and the department or agency with which it was filed.


Alabama Supplemental Claim C Step 2: In section 1, give the claimant's name, mailing address and Social Security or federal identification number. Also enter their home and business telephone numbers.


Alabama Supplemental Claim C Step 3: If the claimant is a minor child, section 1 should be completed by their parent and guardian. If so, on the blank line provided, enter the name and age of the minor and the name and relationship to the minor of the person completing this document.


Alabama Supplemental Claim C Step 4: Section 2 should only be completed if an attorney is representing the claimant and has completed this form. If so, give their name and mailing attorney. This will authorize the attorney to handle correspondence and official communications regarding this return.


Alabama Supplemental Claim C Step 5: In section 3A, indicate if this is a claim for uninsured medical expenses. If so, enter the dollar amount. Indicate with a check mark if you have insurance. If so, enter the name of the insuring company. In section 3B, indicate if this injury resulted in permanent disability. If so, enter the amount sought and give a description of the disability. Enter the rate of pay at the time of accident or injury.


Alabama Supplemental Claim C Step 6: In section 3C, indicate if you are seeking compensation for leave time from work used  for recovery. If so, give the dollar amount of the wages lost or compensation sought for time off work and the number of hours, days or weeks you were unable to work. Give the dates for which you seek compensation and your rate of pay at the time of the incident.


Alabama Supplemental Claim C Step 7: Document miscellaneous expenses you seek compensation for in section 3D and provide an explanation. Total all compensation sought on line 4. Sign the form before a notary public.

Download the PDF file .