Combination Supplementary And Claim Summary Form

MAIL TO: STATE OF ALABAMA Workers' Compensation Division Department of Labor Montgomery, Alabama 36131 COMBINATION SUPPLEMENTARY & CLAIM SUMMARY FORM 1. Employee: 3. Employer: 5. Date of Injury: 7. Insurance carrier: 10. Name, address and telephone number of office filing this report: 2. Social Security number: 4. Unemployment Compensation Number: 6. Date disability began this period: 8. Claim # 9. Service Co # SUPPLEMENTAL REPORT FIRST PAYMENT REINSTATEMENT the amount of (Date of 1st check) AMENDED thru per week. ; Permanent Total ; Fatal A. 1. On $ was paid for the period from Compensation Rate ; $ Average Weekly Wage 2. 3. Type of Disability: Temporary Total ; $ Temporary Partial Permanent Partial If periodic payments were awarded by Circuit Court, give name, location and civil action (CV) number and explain: B. COMPENSATION WAS NOT PAID WITHIN 30 DAYS FROM THE DATE OF DISABILITY BEGAN, COMPLETE THIS SECTION. 4. Reason for non-payment: Medical Only , no lost time (return to work date) Under investigation , reason for prolonged investigation In litigation , Under appeal Has compensation been denied and claimant notified? Yes 5. No Reason? CLAIM SUMMARY FORM SUSPENSION 1. 2. 3. 4. Last day comp was owed and paid Did claimant work during this period of disability? Yes No SETTLEMENT RTW If so, from AMENDED MMI to total days (DO NOT INCLUDE ANY PAYMENTS PREVIOUSLY FILED ON A CLAIM SUMMARY FORM) AWW $ CR (66.7%) $ Amount and type of comp paid: TTD $ WKS TPD $ WKS PPD $ WKS PTD $ WKS Death $ WKS Estate Payment $ Burial Payment LSP $ Date Pd % Part of Body Ombudsman Yes Date No Court CV# Adjuster & Title Signature Days Days Days Days $ % POB WKS Location (County) Days 5. American LegalNet, Inc. www.FormsWorkFlow.com 10/01/2012