INSTRUCTIONS: ALABAMA SUPPLEMENTAL CLAIM (Form C)

The form discussed in this article is used to file a claim for expenses not paid by an Alabama public department or agency. This document can be obtained from the website of the Alabama State Board of Adjustment. 

Alabama Supplemental Claim C Step 1: If this form is a supplement to a previously filed claim, enter the claim number and agency name where indicated.

Alabama Supplemental Claim C Step 2: Section 1 concerns the claimant. On the first two blank lines, enter the name and mailing address of the claimant.

Alabama Supplemental Claim C Step 3: On the third blank line, enter your home phone number, including the area code.

Alabama Supplemental Claim C Step 4: On the fourth blank line, enter your business phone number, including the area code.

Alabama Supplemental Claim C Step 5: On the fifth blank line, enter your Social Security number or federal ID number.

Alabama Supplemental Claim C Step 6: If the injured party is 19 years of age or younger, their parent or guardian must file the form as the claimant. If this is the case, enter the name and age of the minor on the sixth blank line and the name and relationship of the person with whom the minor lives.

Alabama Supplemental Claim C Step 7: Section 2 concerns the claimant's attorney, if applicable. Enter the attorney's name on the first blank line, their mailing address on the second blank line, and their zip code and telephone number on the last two blank lines.

Alabama Supplemental Claim C Step 8: In section 3A, indicate whether this is a claim for uninsured medical expenses with a check mark. If so, enter the amount. Indicate whether you have insurance with a check mark. If so, enter the name of the company.

Alabama Supplemental Claim C Step 9: In section 3B, indicate whether this claim concerns a permanent disability with a check mark. If so, provide all information requested.

Alabama Supplemental Claim C Step 10: In section 3C, indicate whether this claim concerns lost wages or compensation for leave used with a check mark. If so, provide all information requested. In section 3D, indicate whether this claim concerns miscellaneous or other expenses with a check mark. If so, provide all information requested. Sign the form and have it certified by a notary public.

INSTRUCTIONS: ALABAMA DEATH BENEFIT CLAIM FORM (Form B)

As part of the death benefit claim process for survivors of Alabama peace officer or fireman who have had their claim denied, a form B will be filed. This document can be obtained from the website maintained by the Alabama Board of Adjustment.

Alabama Death Benefit Claim Form B Step 1: Enter your name on the first blank line.

Alabama Death Benefit Claim Form B Step 2: On the first three blank lines of line 1, enter your name, mailing address and zip code.

Alabama Death Benefit Claim Form B Step 3: On the next blank line of line 1, enter your home telephone number, including the area code.

Alabama Death Benefit Claim Form B Step 4: On the next blank line of line 1, enter your work telephone number, including the area code.

Alabama Death Benefit Claim Form B Step 5: On line 2, enter the date of death of the peace officer or fireman.

Alabama Death Benefit Claim Form B Step 6: On line 3, enter how long the peace officer or fireman had been employed in that capacity.

Alabama Death Benefit Claim Form B Step 7: Line 4 states that you must attach a death certificate and affidavit from the head of the agency which employed the deceased stating the status of their employment and the circumstances of their death.

Alabama Death Benefit Claim Form B Step 8: In section 5, you must document all surviving dependents in the table provided. In the first column, enter the full name and address of each dependent.

Alabama Death Benefit Claim Form B Step 9: In the second column, enter each dependent's relationship to the deceased.

Alabama Death Benefit Claim Form B Step 10: In the third column, enter each dependent's age.

Alabama Death Benefit Claim Form B Step 11: In the fourth column, indicate whether the deceased was contributing to support each listed dependent.

Alabama Death Benefit Claim Form B Step 12: On line 6, enter the geographic location of the injury or death.

Alabama Death Benefit Claim Form B Step 13: On line 7, state in your own words the circumstances related to the death of the peace officer or fireman.

Alabama Death Benefit Claim Form B Step 14: Sign the form where indicated, then have it certified by a notary public.

INSTRUCTIONS: ALABAMA DEATH BENEFIT CLAIMS EXAMPLES OF SUPPORTING DOCUMENTATION

This article discusses an information document outlining acceptable supporting documentation for support claims due to the death of an Alabama peace officer or fireman. This document can be obtained from the website maintained by the Alabama State Board of Adjustment.

Alabama Death Benefit Claims Examples Of Supporting Documentation Step 1: The first listed acceptable supporting document is a death certificate for the deceased Alabama peace officer or fireman.

Alabama Death Benefit Claims Examples Of Supporting Documentation Step 2: The second listed acceptable supporting document is an accident or incident report, if applicable.

Alabama Death Benefit Claims Examples Of Supporting Documentation Step 3: The third listed acceptable support document is an affidavit from the head of the employing agency or department which must answer several questions about the death of the peace officer or fireman. The first question which must be addressed in this affidavit is if the peace officer or fireman was engaged in the performance of their duties when killed or receiving injuries contributing to their death.

Alabama Death Benefit Claims Examples Of Supporting Documentation Step 4: The second question to be answered in this affidavit is if the peace officer or fireman was engaged in willful misconduct.

Alabama Death Benefit Claims Examples Of Supporting Documentation Step 5: The third question to be answered is if the peace officer or fireman was intoxicated by alcohol or drugs at the time of death and whether tests were conducted with regard to alcohol or drugs.

Alabama Death Benefit Claims Examples Of Supporting Documentation Step 6: The fourth question to be answered is if the peace officer or fireman failed to use safety appliances supplied by their employer.

Alabama Death Benefit Claims Examples Of Supporting Documentation Step 7: The fifth question to be answered is if the peace officer or fireman refused or neglected to perform a statutory duty.

Alabama Death Benefit Claims Examples Of Supporting Documentation Step 8: The sixth question to be answered is if the peace officer or fireman violated a law or willfully breached a reasonable rule or regulation governing the performance of their duties or employment.

Alabama Death Benefit Claims Examples Of Supporting Documentation Step 9: The rest of the form identifies documents acceptable for identifying surviving dependents. 

INSTRUCTIONS: ALABAMA SOUTHLAND BENEFIT SOLUTIONS EMPLOYEE'S STATEMENT

Alabama state employees enrolled in medical coverage administered by Southland Benefit Solutions can use the form discussed in this article to file a claim for a hospital bill. This document can be obtained from the website maintained by Southland Benefit Solutions.

Alabama Southland Benefit Solutions Employee's Statement Step 1: Enter the subscriber's name in box 1.

Alabama Southland Benefit Solutions Employee's Statement Step 2: Enter the subscriber's contract number in box 2.

Alabama Southland Benefit Solutions Employee's Statement Step 3: Enter the subscriber's home address in box 3.

Alabama Southland Benefit Solutions Employee's Statement Step 4: Enter the patient's name in box 4.

Alabama Southland Benefit Solutions Employee's Statement Step 5: Enter the patient's date of birth in box 5.

Alabama Southland Benefit Solutions Employee's Statement Step 6: Enter the patient's age in box 6.

Alabama Southland Benefit Solutions Employee's Statement Step 7: Indicate the patient's sex with a check mark in box 7.

Alabama Southland Benefit Solutions Employee's Statement Step 8: Indicate the patient's relationship to the subscriber with a check mark in box 8.

Alabama Southland Benefit Solutions Employee's Statement Step 9: Enter the subscriber's home and work phone number in box 9.

Alabama Southland Benefit Solutions Employee's Statement Step 10: In box 10, enter the type of illness or injury or the doctor's diagnosis.

Alabama Southland Benefit Solutions Employee's Statement Step 11: In the next blank box, enter the physician's name and address.

Alabama Southland Benefit Solutions Employee's Statement Step 12: In the next blank box, enter the name of the hospital, if confined.

Alabama Southland Benefit Solutions Employee's Statement Step 13: In the next blank box, enter the date you were admitted.

Alabama Southland Benefit Solutions Employee's Statement Step 14: In the next blank box, enter the date you were discharged.

Alabama Southland Benefit Solutions Employee's Statement Step 15: In the next blank box, enter the date the accident or sickness began.

Alabama Southland Benefit Solutions Employee's Statement Step 16: In the next blank box, enter the date the accident or sickness was first treated.

Alabama Southland Benefit Solutions Employee's Statement Step 17: In the next blank box, indicate whether the condition was related to accident or illness.

Alabama Southland Benefit Solutions Employee's Statement Step 18: Sign and date the form where indicated.