Supplementary Report {WC3}

MAIL TO: STATE OF ALABAMA Workers' Compensation Division Department of Labor Montgomery, Alabama 36131 THE USE OF THIS FORM IS REQIRED UNDER THE PROVISIONS OF THE ALABAMA WORKERS' COMPENSATION LAW SUPPLEMENTARY REPORT Please type or print The original of this form must be filed with this office. Copies will not be accepted. FIRST PAYMENT 1. Employee: 3. Employer: 5. Date of Injury: 7. Insurance carrier: 9. Name, address and telephone number of office filing this report: Phone: Ext: A. 10. REINSTATEMENT 2. Social Security number: 4. Unemployment Compensation Number: AMENDED 6. Date disability began this period: 8. Claim # Service Co # On (Date of 1st check) the amount of was paid for the period from thru Average Weekly Wage $ 11. Type of Disability: Temporary Total Compensation Rate $ per week. ; Temporary Partial .; Permanent Partial .; Permanent Total .; Fatal .; 12. If periodic payments are awarded by Circuit Court, give name location and civil action (CV) number and explain: B. IF COMPENSATION WAS NOT PAID WITHIN 30 DAYS FROM THE DATE DISABILITY BEGAN, COMPLETE THIS SECTION. ; no lost time, (return to work date) 13. Reason for non-payment: Medical Only Under investigation ; reason for prolonged investigation In litigation ; Under appeal ; 14. Has compensation been denied and claimant notified? Yes ; No ; Reason? Date Signature and Title WC Form 3 Revised 10-12 American LegalNet, Inc. www.FormsWorkFlow.com