INSTRUCTIONS: ALABAMA COMBINATION SUPPLEMENTARY & CLAIM SUMMARY FORM
When an Alabama company pays workers compensation to an employee injured or involved in an accident on the job, they can file a combination supplementary and claim summary form documenting payments made. This form can be found on the website of the Alabama Department of Labor.
Alabama Combination Supplementary & Claim Summary Form Step 1: The first section must be completed by all filing it. Enter the name of the employee on line 1 and their Social Security number on line 2.
Alabama Combination Supplementary & Claim Summary Form Step 2: Enter the employer name on line 3 and your unemployment compensation number on line 4.
Alabama Combination Supplementary & Claim Summary Form Step 3: Enter the date of the injury on line 5 and the date the disability began this period on line 6.
Alabama Combination Supplementary & Claim Summary Form Step 4: Enter the name of the insurance carrier on line 7, the claim number on line 8, and the service company number on line 9.
Alabama Combination Supplementary & Claim Summary Form Step 5: On line 10, enter the name, address and telephone number of the officer filing this report.
Alabama Combination Supplementary & Claim Summary Form Step 6: The next section is the Supplemental Report. Indicate with a check mark if this documents a first payment or a reinstatement or is an amended return.
Alabama Combination Supplementary & Claim Summary Form Step 7: Complete section A if you have made payment. Enter the amount and period of payment on line 1 and indicate the type of disability with a check mark on line 2. If periodic payments were awarded by a circuit court, give its name and location and the civil action number on line 3.
Alabama Combination Supplementary & Claim Summary Form Step 8: If compensation was not paid within 30 days from the onset of the disability, complete section B.
Alabama Combination Supplementary & Claim Summary Form Step 9: The next section is the Claim Summary Form. Indicate with a check mark if you are filing a form documenting a suspension or settlement or an amended form.
Alabama Combination Supplementary & Claim Summary Form Step 10: Answer all questions on lines 1 through 5.
Alabama Combination Supplementary & Claim Summary Form Step 11: Provide the date, the adjuster name and title and your signature at the bottom of the page.