Get Alabama Labor Claims 2012-2024

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 SETTLEMENT AMENDED 1. Employee 2. S.S.N. 3. Employer 4. STATE OF ALABAMA Workers Compensation Division Department of Labor Montgomery Alabama 36131 Mail to 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 SETTLEMENT AMENDED 1. Employee 2. S*S*N* 3. Employer 4. Unemployment Compensation 5. Date of Injury Date disability began this period 7. Insurance carrier 8. Claim 9. Service Co 10. Name address and telephone number of office filing this report Phone Ext DO NOT INCLUDE ANY PAYMENTS PREVIOUSLY FILED ON A CLAIM SUMMARY FORM 11. Date last day comp paid RTW 12. Did claimant work during this period of disability 13. AWW YES MMI NO If so from 14. Medical pd this period CR 66. 67 15. Amount and type of comp paid TTD WKS Days TPD PPD PTD Death Estate Pmt Burial Payment Future Med LSP Date Pd Part of Body 16. Ombudsman 17. Legal POB Yes Pltf Fees Date WC 4 Revised 10-12 No Location County Court CV Exp Def Fees Signature and Title. STATE OF ALABAMA Workers Compensation Division Department of Labor Montgomery Alabama 36131 Mail to 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 SETTLEMENT AMENDED 1. Employee 2. S*S*N* 3. Employer 4. Unemployment Compensation 5. Date of Injury Date disability began this period 7. Insurance carrier 8. Unemployment Compensation 5. Date of Injury Date disability began this period 7. Insurance carrier 8. Claim 9. Service Co 10. Name address and telephone number of office filing this report Phone Ext DO NOT INCLUDE ANY PAYMENTS PREVIOUSLY FILED ON A CLAIM SUMMARY FORM 11. Claim 9. Service Co 10. Name address and telephone number of office filing this report Phone Ext DO NOT INCLUDE ANY PAYMENTS PREVIOUSLY FILED ON A CLAIM SUMMARY FORM 11. Date last day comp paid RTW 12. Did claimant work during this period of disability 13. AWW YES MMI NO If so from 14. Date last day comp paid RTW 12. Did claimant work during this period of disability 13. AWW YES MMI NO If so from 14. Medical pd this period CR 66. 67 15. Amount and type of comp paid TTD WKS Days TPD PPD PTD Death Estate Pmt Burial Payment Future Med LSP Date Pd Part of Body 16. Medical pd this period CR 66. 67 15. Amount and type of comp paid TTD WKS Days TPD PPD PTD Death Estate Pmt Burial Payment Future Med LSP Date Pd Part of Body 16. Ombudsman 17. Legal POB Yes Pltf Fees Date WC 4 Revised 10-12 No Location County Court CV Exp Def Fees Signature and Title. CLAIMS SUMMARY FORM PLEASE TYPE OR PRINT SUSPENSION SETTLEMENT AMENDED 1. Employee 2. S*S*N* 3. Employer 4. Unemployment Compensation 5. Date of Injury Date disability began this period 7. Insurance carrier 8. Claim 9. Service Co 10. Name address and telephone number of office filing this report Phone Ext DO NOT INCLUDE ANY PAYMENTS PREVIOUSLY FILED ON A CLAIM SUMMARY FORM 11. .