Alabama Employer's First Report of Injury
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THE  USE  OF  THIS  FORM  IS  REQUIRED  UNDER  THE  PROVISIONS  OF  THE  ALABAMA  WORKMEN’S  COMPENSATION  LAW

WCC Form 2
Rev. 10/2012

STATE OF ALABAMA
EMPLOYER’S  FIRST  REPORT  OF  INJURY                
OR OCCUPATIONAL DISEASE

CLAIM REFERENCE
2. Filing Office Claim Number

1. Insured Report Number

3. OSHA Log Case Number

EMPLOYER
ADDRESS, IF LOCATION DIFFERENT FROM BUSINESS ADDRESS
10. Mailing Address 1
11. Mailing Address 2
12. City
13. State
14. Zip
8. State
9. Zip
16. U.C. Account Number
17. NAICS

4. Employer Business Name
5. Physical Address 1
6. Physical Address 2
7. City
15. Federal ID Number

INSURER / FILING OFFICE
18. Insurer Name
19. Insurer Federal ID Number
20. Type Insurer

Ins Co

Self-Insurer

Group Fund

21. Filing Office Name
22. Mailing Address 1
23. Mailing Address 2 or Telephone Number
24. City
25. State
27. Filing Office Federal ID Number

26. Zip

EMPLOYEE / WAGES
28. First Name
29. Middle Name
30. Last Name
31 Last Name Suffix (ie. Jr., Sr., III)
34. Mai