INSTRUCTIONS: ALABAMA SOUTHLAND BENEFIT SOLUTIONS EMPLOYEE'S STATEMENT

To file a statement as a public employee enrolled in a plan administered by Southland Benefit Solutions in connection with injury or accident related to Alabama employment, the document discussed in this article is used. This document can be obtained from the website maintained

Alabama Southland Benefit Solutions Employee's Statement Step 1: Enter the subscriber's name in box 1.

Alabama Southland Benefit Solutions Employee's Statement Step 2: Enter the subscriber's contract number in box 2.

Alabama Southland Benefit Solutions Employee's Statement Step 3: Enter the subscriber's home address in box 3.

Alabama Southland Benefit Solutions Employee's Statement Step 4: Enter the patient's name in box 4.

Alabama Southland Benefit Solutions Employee's Statement Step 5: Enter the patient's date of birth in box 5.

Alabama Southland Benefit Solutions Employee's Statement Step 6: Enter the patient's age in box 6.

Alabama Southland Benefit Solutions Employee's Statement Step 7: Indicate the patient's gender with a check mark in box 7.

Alabama Southland Benefit Solutions Employee's Statement Step 8: Indicate the patient's relationship to the subscriber with a check mark in box 8.

Alabama Southland Benefit Solutions Employee's Statement Step 9: Enter the subscriber's home and work phone numbers in box 9.

Alabama Southland Benefit Solutions Employee's Statement Step 10: Enter the type of illness or injury or the doctor's diagnosis in box 10.

Alabama Southland Benefit Solutions Employee's Statement Step 11: Enter the name of the physician and their address in the next blank box.

Alabama Southland Benefit Solutions Employee's Statement Step 12: Enter the name of the hospital, if confined, in the next blank box.

Alabama Southland Benefit Solutions Employee's Statement Step 13: Enter the date of admission and the date you were discharged in the next two blank boxes.

Alabama Southland Benefit Solutions Employee's Statement Step 14: Enter the date the accident or sickness began and the date you were first treated in the next two blank boxes.

Alabama Southland Benefit Solutions Employee's Statement Step 15: Indicate whether condition was related to accident or illness with a check mark.

Alabama Southland Benefit Solutions Employee's Statement Step 16: Enter the date and your signature where indicated.

Alabama Southland Benefit Solutions Employee's Statement Step 17: Submit the form to the attending physician, who will complete the remainder.