Alabama Supplementary Report Form
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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

REINSTATEMENT

AMENDED

1. Employee:

2. Social Security number:

3. Employer:

4. Unemployment Compensation Number:

5. Date of Injury:

6. Date disability began this period:

7. Insurance carrier:

8. Claim #

Service Co #

9. Name, address and telephone number of office filing this report:
Phone:
Ext:
A.
10.

On

the amount of

was paid for the period from

thru

(Date of 1st check)

Average Weekly Wage $
11.

12.

Type of Disability:
Temporary Total

Compensation Rate $

; Temporary Partial

.;

Permanent Partial

.;

per week.

Permanent Total

.;

Fatal

If periodic payments are awarded by Circuit Court, give name location and civil action (