INSTRUCTIONS: ALABAMA COMBINATION SUPPLEMENTARY & CLAIM SUMMARY FORM

Alabama businesses use the form discussed in this article to document compensation paid or not paid through workers' compensation insurance for an on-the-job injury. This document can be obtained from the website maintained by the Alabama Department of Labor.

Alabama Combination Supplementary & Claim Summary Form Step 1: On line 1, enter the name of the employee.

Alabama Combination Supplementary & Claim Summary Form Step 2: On line 2, enter the employee's Social Security number.

Alabama Combination Supplementary & Claim Summary Form Step 3: On line 3, enter the name of the employer.

Alabama Combination Supplementary & Claim Summary Form Step 4: On line 4, enter the business unemployment compensation number.

Alabama Combination Supplementary & Claim Summary Form Step 5: On line 5, enter the date of the injury.

Alabama Combination Supplementary & Claim Summary Form Step 6: On line 6, enter the date the disability began this period.

Alabama Combination Supplementary & Claim Summary Form Step 7: On line 7, enter the name of your insurance carrier.

Alabama Combination Supplementary & Claim Summary Form Step 8: On line 8, enter the claim number.

Alabama Combination Supplementary & Claim Summary Form Step 9: On line 9, enter the service company number.

Alabama Combination Supplementary & Claim Summary Form Step 10: On line 10, enter the name, address and telephone number of the office filing this report.

Alabama Combination Supplementary & Claim Summary Form Step 11: The next section of this form contains the supplemental report section. Indicate whether this concerns a first payment, reinstatement or an amended form with a check mark.

Alabama Combination Supplementary & Claim Summary Form Step 12: On line 1, give the date of the first check, the amount, the beginning and ending dates of the period it covered, the worker's average weekly wage and their compensation rate.

Alabama Combination Supplementary & Claim Summary Form Step 13: Indicate the type of disability on line 2 with a check mark.

Alabama Combination Supplementary & Claim Summary Form Step 14: Complete the rest of the section as instructed.

Alabama Combination Supplementary & Claim Summary Form Step 15: The next section is the claim summary form. Indicate whether this concerns a suspension, settlement or an amended form with a check mark.

Alabama Combination Supplementary & Claim Summary Form Step 16: Complete the rest of the form as instructed and sign where indicated.