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Supplemental Claim Form

Supplemental Claim Form

 

INSTRUCTIONS: ALABAMA SUPPLEMENTAL CLAIM (Form C)

 

 

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.

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Form WC 4 Claims Summary Form

Form WC 4 Claims Summary Form

 

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.
 

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Death Benefit Claim Form

Death Benefit Claim Form

 

INSTRUCTIONS: ALABAMA DEATH BENEFIT CLAIM FORM (Form B)

 

 

When an Alabama peace officer or fireman dies, their survivors may seek death benefits from the state by filing a form B death benefit claim form. This document can be obtained from the website of the Alabama Department of Finance. You must print or type all of your answers in ink.

 

Alabama Death Benefit Claim Form B Step 1: Enter your name on the line above the words "Name of Claimant."

 

Alabama Death Benefit Claim Form B Step 2: On line 1, enter your name and mailing address, as well as your home and business telephone numbers.

 

Alabama Death Benefit Claim Form B Step 3: On line 2, give the date of death of the fireman or police officer.

 

Alabama Death Benefit Claim Form B Step 4: On line 3, give the duration of the deceased's employment in that capacity.

 

Alabama Death Benefit Claim Form B Step 5: Line 4 states that you must attach a death certificate as documentation for your claim. You must also include an affidavit from the head of the agency which employed the deceased which states their employment status and provides a description of the circumstances leading to their death.

 

Alabama Death Benefit Claim Form B Step 6: Line 5 requires you to enter all surviving dependents, including spouses, children from a current or previous marriage and parents. Attach additional sheets as necessary. Give the full name and address of every dependent, as well as their relationship to the deceased and their age. Note whether they were receiving support from the deceased.

 

Alabama Death Benefit Claim Form B Step 7: On line 6, give the geographic location of the site of injury or death.

 

Alabama Death Benefit Claim Form B Step 8: On line 7, provide your explanation of the circumstances of death, including the name of the deceased. Attach additional sheets as necessary.

 

Alabama Death Benefit Claim Form B Step 9: If you are represented by an attorney, enter their name, address and telephone number.

 

Alabama Death Benefit Claim Form B Step 10: Sign the form in the presence of a notary public.

 

Alabama Death Benefit Claim Form B Step 11: File the form in duplicate along with all supporting documentary evidence. This must also be submitted in duplicate. 

 

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BC/BS Expense Claim

BC/BS Expense Claim

 

INSTRUCTIONS: BLUE CROSS/BLUE SHIELD OF ALABAMA MEDICAL EXPENSE CLAIM

 

 

Those who are enrolled for medical insurance through Blue Cross/Blue Shield of Alabama should file the medical expense claim discussed in this article when their physician or provider does not file a claim. This form can be found on the website of the Alabama State Employees' Insurance Board, which administers Blue Cross/Blue Shield insurance to state workers.

 

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 1: In box 1, enter the patient's name.

 

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 2: In box 2, enter your contract number as shown on your identification card.

 

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 3: In box 3, enter your group number as shown on your identification card or place of employment.

 

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 4: In box 4, enter the patient's date of birth.

 

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 5: In box 5, indicate the patient's gender with a check mark.

 

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 6: In box 6, indicate the patient's relationship to the contract holder with a check mark. If not the person holding the policy, their spouse or child, explain.

 

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 7: In box 7, give the name, address and telephone number of the contract holder.

 

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 8: In box 8, indicate with a check mark whether the patient is covered under any other group health insurance plan. If so, give the name of the policy holder of that plan, the name and address of the insuring company, the policy identification number and the date on which it became effective.

 

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 9: In box 9, indicate if the patient's condition was related to their employment, an auto accident, or another accident or injury.

 

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 10: In box 10, enter the diagnoses.

 

Blue Cross/Blue Shield Of Alabama Medical Expense Claim Step 11: In box 11, give the phone number, name and address of the ordering physician. Sign and date the bottom of the form.

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Worker’s Compensation Combination Supplementary and Claim Summary Form

Worker's Compensation Combination Supplementary and Claim Summary Form

 

INSTRUCTIONS: ALABAMA COMBINATION SUPPLEMENTARY & CLAIM SUMMARY FORM

 

 

Alabama businesses use the form discussed in this article to document compensation paid or not paid through workers' compensation insurance for an on-the-job injury. This document can be obtained from the website maintained by the Alabama Department of Labor.

 

Alabama Combination Supplementary & Claim Summary Form Step 1: On line 1, enter the name of the employee.

 

Alabama Combination Supplementary & Claim Summary Form Step 2: On line 2, enter the employee's Social Security number.

 

Alabama Combination Supplementary & Claim Summary Form Step 3: On line 3, enter the name of the employer.

 

Alabama Combination Supplementary & Claim Summary Form Step 4: On line 4, enter the business unemployment compensation number.

 

Alabama Combination Supplementary & Claim Summary Form Step 5: On line 5, enter the date of the injury.

 

Alabama Combination Supplementary & Claim Summary Form Step 6: On line 6, enter the date the disability began this period.

 

Alabama Combination Supplementary & Claim Summary Form Step 7: On line 7, enter the name of your insurance carrier.

 

Alabama Combination Supplementary & Claim Summary Form Step 8: On line 8, enter the claim number.

 

Alabama Combination Supplementary & Claim Summary Form Step 9: On line 9, enter the service company number.

 

Alabama Combination Supplementary & Claim Summary Form Step 10: On line 10, enter the name, address and telephone number of the office filing this report.

 

Alabama Combination Supplementary & Claim Summary Form Step 11: The next section of this form contains the supplemental report section. Indicate whether this concerns a first payment, reinstatement or an amended form with a check mark.

 

Alabama Combination Supplementary & Claim Summary Form Step 12: On line 1, give the date of the first check, the amount, the beginning and ending dates of the period it covered, the worker's average weekly wage and their compensation rate.

 

Alabama Combination Supplementary & Claim Summary Form Step 13: Indicate the type of disability on line 2 with a check mark.

 

Alabama Combination Supplementary & Claim Summary Form Step 14: Complete the rest of the section as instructed.

 

Alabama Combination Supplementary & Claim Summary Form Step 15: The next section is the claim summary form. Indicate whether this concerns a suspension, settlement or an amended form with a check mark.

 

Alabama Combination Supplementary & Claim Summary Form Step 16: Complete the rest of the form as instructed and sign where indicated.

 

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