INSTRUCTIONS: ALABAMA NOTICE OF COVERAGE (WC Form 8)

To provide notification to the state of Alabama of workers compensation coverage being provided by your business, you should file a form WC 8. This document can be found on the website maintained by the Alabama Department of Labor.

Alabama Notice Of Coverage WC 8 Step 1: On the first line, enter your state unemployment compensation tax number.

Alabama Notice Of Coverage WC 8 Step 2: On the second line, enter your federal identification number.

Alabama Notice Of Coverage WC 8 Step 3: On the third line, enter the name of your limited liability company or corporation.

Alabama Notice Of Coverage WC 8 Step 4: On the fourth line, enter the trade name ("doing business as") of your corporation or limited liability company.

Alabama Notice Of Coverage WC 8 Step 5: On the fifth line, enter your primary business address.

Alabama Notice Of Coverage WC 8 Step 6: On the sixth line, enter all other locations which you are covering.

Alabama Notice Of Coverage WC 8 Step 7: On the seventh line, provide a brief description of the nature of your business operations.

Alabama Notice Of Coverage WC 8 Step 8: On the eighth line, enter your North American Industry Classification System (NAICS) number. If you do not know what your NAICS number is, a complete list is available on the website of the Alabama Department of Labor.

Alabama Notice Of Coverage WC 8 Step 9: On the ninth line, enter the date on which the policy will take effect.

Alabama Notice Of Coverage WC 8 Step 10: On the tenth line, enter the expiration date of this policy.

Alabama Notice Of Coverage WC 8 Step 11: On the eleventh line, enter your policy number.

Alabama Notice Of Coverage WC 8 Step 12: On the twelfth line, enter the name of the insurance carrier.

Alabama Notice Of Coverage WC 8 Step 13: On the thirteenth line, enter your NCCI code.

Alabama Notice Of Coverage WC 8 Step 14: File the form by mailing it to the address given at the top of the form.

Alabama Notice Of Coverage WC 8 Step 15: If you decide to cancel this coverage at a later date, you will need to notify the Alabama Department of Labor by filing a form WC 9.

INSTRUCTIONS: SOUTHLAND NATIONAL INDEMNITY AND CANCER CLAIM FORM

Alabama current and retired public employees who have received medical care for cancer and other conditions should file a claim for medical insurance compensation with Southland Benefit Solutions, the designated provider for state government workers. The document discussed in this article can be found on the website of the Retirement Systems of Alabama.  

Southland National Indemnity And Cancer Claim Form Step 1: The top half of the form is the employee's statement. Enter your name and subscription contract number in boxes 1 and 2.

Southland National Indemnity And Cancer Claim Form Step 2: Enter your home address in box 3.

Southland National Indemnity And Cancer Claim Form Step 3: Enter your name in box 5, date of birth in box 6 and age in box 7.

Southland National Indemnity And Cancer Claim Form Step 4: Indicate your gender in box 8 with a check mark.

Southland National Indemnity And Cancer Claim Form Step 5: In box 8, indicate with a check mark whether the patient is the subscriber, their spouse or their child.

Southland National Indemnity And Cancer Claim Form Step 6: Give the subscriber's telephone number in box 9.

Southland National Indemnity And Cancer Claim Form Step 7: In box 10, give a description of your injury or illness or the doctor's diagnosis.

Southland National Indemnity And Cancer Claim Form Step 8: Enter the physician's name and address, the name of your hospital if confined, the dates of your admission and discharge, the date your accident occurred or sickness began and the date you first received treatment. 

Southland National Indemnity And Cancer Claim Form Step 9: Indicate with a check mark whether your condition was related to accident or illness.

Southland National Indemnity And Cancer Claim Form Step 10: Sign and date the top half of the form.

Southland National Indemnity And Cancer Claim Form Step 11: The bottom half of the form is the attending physician's statement which documents the services you received and provides identifying information about the doctor. This should be completed by your doctor and then returned to you.

Southland National Indemnity And Cancer Claim Form Step 12: Mail the completed form along with an itemized copy of your hospital bill to the address listed on the second page.

INSTRUCTIONS: ALABAMA SUPPLEMENTARY REPORT (WC Form 3)

Alabama employers are required to file a WC Form 3 whenever payment is made to a worker injured on the job. This document can be found on the website of the Alabama Department of Labor.

Alabama Supplementary Report WC 3 Step 1: Indicate with a check mark if this report documents a first payment, a reinstatement, or is an amended report.

Alabama Supplementary Report WC 3 Step 2: On line 1, enter the name of the employee. On line 2, enter their Social Security number.

Alabama Supplementary Report WC 3 Step 3: On line 3, enter the name of the employer. On line 4, enter their unemployment compensation number.

Alabama Supplementary Report WC 3 Step 4: On line 5, enter the date on which the injury occurred.

Alabama Supplementary Report WC 3 Step 5: On line 6, enter the date in this period on which the disability began.

Alabama Supplementary Report WC 3 Step 6: On line 7, enter the name of your insurance carrier. 

Alabama Supplementary Report WC 3 Step 7: On line 8, enter your claim and service company numbers.

Alabama Supplementary Report WC 3 Step 8: On line 9, provide the name, address and telephone number of the officer completing this report.

Alabama Supplementary Report WC 3 Step 9: On line 10, enter the date on which the first check was cut, the amount, and the dates for which it was paid. Also enter the worker's average weekly wage and compensation rate per week.

Alabama Supplementary Report WC 3 Step 10: On line 11, indicate with a check mark if the disability was temporary total, temporary partial, permanent partial, permanent total, or if the incident resulted in a fatality.

Alabama Supplementary Report WC 3 Step 11: If periodic payments were awarded by a circuit court, enter its name and location and the civil action number on line 12.

Alabama Supplementary Report WC 3 Step 12: If payment was not made within 30 days from the date the disability began, explain why on line 13.

Alabama Supplementary Report WC 3 Step 13: If compensation was denied and the claimant was notified, note this on line 14 and explain why.

Alabama Supplementary Report WC 3 Step 14: Sign and date the form, as well as providing your title.

INSTRUCTIONS: SOUTHLAND DENTAL CLAIM FORM 

Alabama public employees are enrolled with Southland Benefit Solutions for their health insurance. Those needing to make a claim for reimbursement for dental treatment should file the form discussed in this article, which is found on the website of the Retirement Systems of Alabama.

Southland Dental Claim Form Step 1: In box 1, indicate with check marks what type of transaction this form documents. In box 2, enter your predetermination or preauthorization number. In box 3, enter the name of your insurance company or dental benefit plan and its address.

Southland Dental Claim Form Step 2: Box 4 asks you to indicate with a check mark if you have other dental or medical coverage. If you check "No," skip to box 12. If you check "Yes," you must complete boxes 5 through 11.

Southland Dental Claim Form Step 3: In box 5, give the name of the policyholder of the other insurance or dental benefits plan. In box 6 give their age, indicate their gender in box 7, give their subscription identification number in box 8, and their plan or group number in box 9. Indicate the patient's relationship to the policyholder with a check mark in box 10. Give the name of the plan and its address in box 11.

Southland Dental Claim Form Step 4: In box 12, enter the name of the policyholder or subscriber to the dental or medical insurance plan for which you are submitting a claim. In box 13 give their date of birth and indicate their gender with a check mark in box 14. Enter their subscription identification number in box 15, their plan or group number in box 16, and their employer's name in box 17.

Southland Dental Claim Form Step 5: In box 18, indicate with a check mark if the patient is the policy holder or their spouse or child. If you are a student, indicate whether you are part or full time in box 19. In box 20, give the patient's name and address. In box 21, give their date of birth. In box 22, indicate their gender with a check mark. In box 23, give the patient's identification or account number. 

Southland Dental Claim Form Step 6: Sections 24 through 33 document all services provided. Boxes 34 and 35 concern missing teeth. The patient and dentist should complete all sections below.

INSTRUCTIONS: ALABAMA CLAIM FORM (Form A)

Alabama public employees can use a form A as part of the claims process related to an on-the-job accident or injury. This documentary can be obtained from the website maintained by the Alabama State Board of Adjustment.

Alabama Claim Form A Step 1: If this is a supplemental claim form, enter the original claim number and the department or agency it concerns.

Alabama Claim Form A Step 2: On the first two blank lines of section 1, enter the name and mailing address of the claimant.

Alabama Claim Form A Step 3: On the next blank line of section 1, enter the claimant's home telephone number.

Alabama Claim Form A Step 4: On the next blank line, enter the claimant's work phone number.

Alabama Claim Form A Step 5: On the next blank line, enter the claimant's Social Security number or federal ID number.

Alabama Claim Form A Step 6: If the injured party is under 19 years of age, the claim must be filed and signed by the parent or guardian. If this is the case, on the next blank line enter the name and age of the minor and the name and relationship to them of the person acting as claimant.

Alabama Claim Form A Step 7: On the first blank line of section 2, enter the name of the claimant's attorney if applicable. In the rest of the section, enter their mailing address, zip code and telephone number.

Alabama Claim Form A Step 8: In section 3, enter the date of the accident or injury.

Alabama Claim Form A Step 9: In section 4, if this claim does not concern an accident or injury, enter the date on which the claim arose.

Alabama Claim Form A Step 10: In section 5, enter the location where the injury or damage occurred.

Alabama Claim Form A Step 11: Section 6 requires you to give a statement of the facts in your own words.

Alabama Claim Form A Step 12: Section 7 requires you to indicate what the claim is made for.

Alabama Claim Form A Step 13: Section 8 concerns damages to personal property.

Alabama Claim Form A Step 14: Section 9 concerns miscellaneous or other expenses.

Alabama Claim Form A Step 15: Enter the total amount claimed in section 10 and other payments made in section 11. Sign section 12.