Claims Summary Form {WC4}

Mail to: STATE OF ALABAMA Workers' Compensation Division Department of Labor Montgomery, Alabama 36131 The original of this form must be filed with this office. Copies will not be accepted. The use of this form is required under the provisions of the Alabama Workers' Compensation Law. CLAIMS SUMMARY FORM PLEASE TYPE OR PRINT SUSPENSION 1. Employee: 3. Employer: 5. Date of Injury: 7. Insurance carrier: 10. Name, address and telephone number of office filing this report: Phone: Ext: 6. SETTLEMENT 2. S.S.N. 4. Unemployment Compensation # Date disability began this period 8. Claim # 9. Service Co # AMENDED (DO NOT INCLUDE ANY PAYMENTS PREVIOUSLY FILED ON A CLAIM SUMMARY FORM) 11. Date last day comp paid 12. Did claimant work during this period of disability? 13. AWW TTD $ TPD $ PPD $ PTD $ Death $ Estate Pmt $ LSP $ % 16. Ombudsman 17. Legal: Yes Pltf Fees $ Part of Body No Court CV# Exp $ Def Fees $ Location (County) Exp $ CR (66.67%) WKS WKS WKS WKS WKS Burial Payment $ Date Pd Days Days Days Future Med $ WKS Days % POB 15. Amount and type of comp paid: Days YES RTW NO If so, from 14. Medical pd this period MMI Date WC 4 Revised 10-12 Signature and Title American LegalNet, Inc. www.FormsWorkFlow.com