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The Alabama First Report form is a critical document in the context of workplace injuries and occupational diseases. This form, which is required under Alabama's Workmen’s Compensation Law, serves several key functions to ensure that employers report injuries promptly and accurately. It captures essential information, including the employer and employee details, the specifics of the injury, and the treatment provided. Notably, the form requests information such as the employer's name, address, and federal ID number, alongside the employee's personal details, including their Social Security number and date of birth. Additionally, it necessitates reporting the nature of the injury, where the incident occurred, and how the injury happened. Employers must describe the circumstances of the incident, which helps in assessing the circumstances surrounding each case. Additionally, the form includes information about the initial treatment received, ensuring that all relevant medical attention is documented. An efficient submission of this form is vital for initiating the claims process and protects both employees and employers under the law.

Alabama First Report Example

THE USE OF THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE ALABAMA WORKMEN’S COMPENSATION LAW

WCC Form 2

Rev. 10/2012STATE OF ALABAMA

EMPLOYER’S FIRST REPORT OF INJURY

OR OCCUPATIONAL DISEASE

CLAIM REFERENCE

 

 

1. Insured Report Number

 

 

2. Filing Office Claim Number

 

 

 

 

 

3. OSHA Log Case Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. Employer Business Name

 

 

 

 

 

 

ADDRESS, IF LOCATION DIFFERENT FROM BUSINESS ADDRESS

 

 

 

5. Physical Address 1

 

 

 

 

 

 

 

 

10. Mailing Address 1

 

 

 

 

 

 

 

 

 

 

 

 

6. Physical Address 2

 

 

 

 

 

 

 

 

11. Mailing Address 2

 

 

 

 

 

 

 

 

 

 

 

 

7. City

 

 

 

 

8. State

 

9. Zip

 

12. City

 

 

 

 

 

 

 

 

13. State

14. Zip

 

 

 

15. Federal ID Number

 

 

16. U.C. Account Number

 

 

 

 

 

17. NAICS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSURER / FILING OFFICE

 

 

 

 

 

 

 

 

 

 

 

18.

Insurer Name

 

 

 

 

 

 

 

 

 

21. Filing Office Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22. Mailing Address 1

 

 

 

 

 

 

 

 

 

 

 

19.

Insurer Federal ID Number

 

 

 

 

 

23. Mailing Address 2 or Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

24. City

 

 

 

 

 

 

 

 

25. State

26. Zip

 

 

20.

Type Insurer

Ins Co

Self-Insurer

 

Group Fund

 

27. Filing Office Federal ID Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYEE / WAGES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

28. First Name

 

 

 

 

 

 

 

 

 

 

 

 

32. Employee ID Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

29. Middle Name

 

 

 

 

 

 

 

 

 

 

 

 

33. Type Employee ID Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

30.

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

SSN

Passport Number

Green Card

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

31

Last Name Suffix

(ie. Jr., Sr., III)

 

 

 

 

 

 

 

 

Employment Visa

 

Assigned by Jurisdiction

 

 

34.

Mailing Address 1

 

 

 

 

 

 

 

 

 

 

 

 

40. Gender

 

 

 

41. Date of Birth

 

 

35.

Mailing Address 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

 

 

 

 

 

 

 

 

36.

City

 

 

 

37. State

 

38. Zip

39. Phone

 

 

 

 

 

Female

 

42.Nbr of Dependents

 

 

43.

Marital Status

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

44. Date Hired

 

 

 

 

 

Unmarried (Single or Divorced or Widowed)

 

Married

 

Separated

 

Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

45.

Occupation Description

 

 

 

 

 

 

 

 

 

 

 

 

 

46. Number of Days Worked Per Week

 

 

47.

Wages $

 

 

 

 

 

 

 

 

 

49. Received Full Pay For Day of Injury?

 

Yes

No

 

 

 

48. Hourly

Daily

Weekly

Bi-weekly

 

Monthly

 

50. Did Salary Continue?

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INJURY / TREATMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

51.

Date of Injury

 

52. Time of Injury

 

 

53. Time Employee Began Work

 

54. Date Disability Began

 

55. Date of Death

 

 

 

 

 

 

 

 

a.m.

p.m.

unk

 

 

a.m.

p.m.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLACE OF ACCIDENT, INJURY, OR EXPOSURE

 

 

 

 

 

 

61. Injury Occurred on Employer’s Premises?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

56.

Site Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

57.

City

 

 

 

 

 

58. State

59. Zip

 

 

62. Date Employer Notified

 

 

 

 

 

60.

County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

63. DESCRIBE WHAT THE EMPLOYEE WAS DOING JUST BEFORE THE INCIDENT AND HOW THE INJURY OCCURRED. ( Ex. While climbing a

ladder and carrying roofing materials, ladder slipped on wet floor causing worker to fall 20 feet.)

PROVIDE DESCRIPTION CODES to identify Nature of Injury, Part of Body that was affected, and Cause of Injury.

 

(FOR COMPLETE LIST OF CODES, GO TO HTTP:// LABOR.ALABAMA.GOV/WC

 

 

64. Nature of Injury Code

 

65. Part of Body Code

66.

 

Cause of Injury Code

67. Initial Treatment

No Medical Treatment

 

68.

Name of Treatment Facility

 

 

First Aid By Employer

Minor Clinic / Hospital

 

 

 

 

69.

Address

 

 

 

 

Emergency Room

Hospitalized Overnight

 

 

 

 

 

 

70.

City

71. State

 

72. Zip

Hospitalized > 24 Hours

Outpatient Treatment

 

 

 

 

 

 

 

 

 

 

73. Name of Physician or Other Health Care Professional

 

 

 

74. Has Injured Returned to Work

 

If so, 75. Date

 

 

 

 

 

 

Yes

No

 

76. Time

a.m. p.m.

 

 

 

 

 

 

 

 

 

 

OTHER

77. Date Prepared

78. Preparer’s First Name

79. Last Name

80. Title

81. Preparer’s Telephone Number

03/01/2006

File Breakdown

Fact Name Fact Detail
Governing Law This form is required under the Alabama Workmen's Compensation Law.
Form Purpose The Alabama First Report Form serves to report workplace injuries or occupational diseases.
Insurer Information Details about the insurer must be included, such as the name and federal ID number.
Employee Identification Includes critical employee details such as name, SSN, and employee ID number.
Injury Reporting The form requires specifics about the injury, including date, time, and description of the incident.
Treatment Information Documents any medical treatment received, including facility name and type of treatment.
Filing Deadline The form should be filed promptly following an injury, ensuring timely reporting as per regulations.
Dependents and Marital Status Information about dependents and marital status is essential, influencing workers' compensation benefits.

Guide to Using Alabama First Report

Completing the Alabama First Report form is an essential step for documenting an employee's work-related injury or occupational disease. Once the form is filled out, it should be submitted to the appropriate authorities. Here are the steps to guide you through the process.

  1. Gather necessary information: Collect details about the employer, employee, injury, and treatment.
  2. Employer information: Fill in the business name, physical address, mailing address, federal ID number, and U.C. account number.
  3. Insurer details: Provide the insurer name, federal ID number, type of insurer, and filing office information.
  4. Employee information: Enter the employee’s name, address, gender, date of birth, marital status, number of dependents, occupation, and number of workdays per week.
  5. Wages: Indicate the employee's wages and whether they received full pay on the day of the injury.
  6. Injury details: Record the date and time of injury, time the employee began work, date disability began, and if applicable, the date of death.
  7. Place of accident: Indicate whether the injury occurred on the employer’s premises and provide the site address and county information.
  8. Description of incident: Clearly explain what the employee was doing before the injury and describe how it occurred.
  9. Injury codes: Enter the nature of the injury code, part of the body affected code, and cause of injury code.
  10. Treatment information: Indicate initial treatment received, name and address of the treatment facility, and the physician’s name.
  11. Return to work: Specify whether the injured employee has returned to work along with the date and time.
  12. Preparation details: Complete the date prepared, preparer's name, title, and telephone number.

Make sure all sections are filled in accurately and double-check the information before submitting the form to avoid any delays in processing your claim. Remember to keep a copy for your records as well.

Get Answers on Alabama First Report

What is the Alabama First Report form?

The Alabama First Report form is a mandatory document used to report workplace injuries or occupational diseases under the Alabama Workmen’s Compensation Law. Employers must complete this form whenever an employee is injured on the job or experiences a work-related illness.

Who is required to file the Alabama First Report form?

Employers who operate in Alabama and have employees are required to file this form when a workplace injury occurs. This includes companies of all sizes, regardless of whether they are private or public entities. It ensures that the employee's claim for workers' compensation can be processed efficiently.

What information is needed to fill out the form?

The form requires detailed information about the incident, the employer, and the injured employee. Key information includes:

  • Employer’s business name and addresses
  • Employee’s full name and contact information
  • Details of the injury, including date, time, and location
  • Nature of the injury and initial medical treatment received

Gathering accurate and complete information will help in processing the claim smoothly.

When must the Alabama First Report form be submitted?

The form must be submitted promptly, usually within a specific time frame after the injury occurs. Typically, the form should be filed within 15 days of the incident to ensure compliance with legal requirements and to facilitate timely processing of the employee's claim.

What happens if the form is not filed?

If the employer fails to file the Alabama First Report form, it may result in penalties, including fines. Additionally, the employee may face delays in receiving workers' compensation benefits, or their claim may be denied altogether. It's crucial to submit the form on time to avoid these issues.

Where can the form be obtained?

The Alabama First Report form can be obtained online through the Alabama Department of Labor's website. You can also access it at various local offices or request it from your insurance carrier. Ensure you are using the most recent version of the form to meet current legal standards.

Common mistakes

When completing the Alabama First Report form, individuals often stumble upon common errors that can cause processing delays or issues down the line. A crucial mistake is failing to provide all required employer information. Missing details such as the employer's physical address or correct Federal ID number can lead to significant complications.

Another frequent oversight involves the employee's information. Inaccurately recording the employee's Social Security number or failing to include the full name can hinder the identification process. It's vital that each designation is correct. Incorrect answers to basic questions regarding the employee's position or wage can cause problems when determining eligibility for benefits.

People also often neglect to provide a clear and comprehensive explanation of the injury incident. The specifics of what the employee was doing at the time of the injury are necessary for both verification and evaluation of the claim. A vague description can result in subsequent inquiries or even denial of the claim.

Using outdated or incorrect codes for describing the nature of the injury and cause can be another pivotal error. The form requires specific injury codes, and any deviation could impair the claim’s processing. Applicants should review the official guidelines for these codes to ensure accuracy.

Additionally, many applicants forget to indicate whether the employee received full pay for the day of the injury. Marking "yes" or "no" is significant for assessing compensation eligibility. Not addressing this question can mislead the claims process and result in misunderstandings regarding wage replacement.

Atypical yet common mistakes include omitting the mailing address for necessary parties or failing to record the correct date of the accident. Each piece of information plays a crucial role, and inconsistencies can lead to delays in the claim's evaluation.

Another misstep involves not adequately specifying whether the injury occurred on the employer's premises. This is a fundamental question that impacts the claim’s validity. The answer should reflect whether the incident took place at a designated workplace location.

Many fail to document the time of the injury accurately. Both the arrival time at work and the time of injury should be clearly specified. Without these details, the timeline of the accident may seem inconsistent, raising questions from reviewers.

Lastly, individuals often neglect to provide the preparer’s contact information, including their name and telephone number. This may appear minor, but in the event of further inquiries, having a contact person linked to the report is essential for efficient communication.

Understanding and correcting these mistakes during the filing process can streamline claims and help ensure a fair assessment of workers' compensation. By carefully reviewing each section, individuals can avoid pitfalls that could lead to unnecessary complications.

Documents used along the form

The Alabama First Report form is an essential document for reporting workplace injuries or occupational diseases. However, it is often accompanied by several other forms that help clarify and provide additional information regarding the claim. Here are some commonly used forms and documents in conjunction with the Alabama First Report.

  • Employee's Claim for Benefits Form: This form is completed by the injured employee to formally request benefits under the Alabama Workers' Compensation system. It details the injury and medical treatment received.
  • Medical Report: This document provides the employer and insurance company with a detailed account of the employee's medical condition following the injury. It typically includes diagnosis, treatment plan, and prognosis.
  • Incident Report: Produced by the employer, this document outlines the facts surrounding the accident, including the location, conditions, and any witnesses. It serves to provide context to the injury.
  • Witness Statements: These are written accounts from individuals who witnessed the incident. They can support or refute claims about the circumstances of the injury.
  • Return to Work Authorization: Issued by a healthcare provider, this form specifies when and under what conditions the injured employee may return to work. It often includes any restrictions related to their duties.
  • Payroll Records: Employers may need to provide payroll records to confirm the employee's earnings at the time of the injury. This information is crucial for calculating wage-loss benefits.
  • Notice of Injury Form: This form is often used to formally notify the worker’s compensation insurance carrier about the injury. It assists in the initiation of the claim process.
  • Independent Medical Examination Report: In certain cases, this report is generated after a third-party medical examination. It evaluates the injury and helps determine eligibility for benefits.
  • Settlement Agreement: If the claim is settled, this document outlines the terms agreed upon by both parties, including compensation amounts and any terms regarding future care.

Each of these documents plays a vital role in the workers' compensation process, providing necessary information to ensure claims are handled appropriately. Understanding their purpose can help both employees and employers navigate the complexities of workplace injury claims more effectively.

Similar forms

  • OSHA Form 300 - Similar to the Alabama First Report form, OSHA Form 300 tracks workplace injuries and illnesses. Both documents serve the purpose of recording events that may affect workplace safety and health.
  • State Workers' Compensation Claim Form - Like the Alabama First Report, this form is designed for reporting work-related injuries to the relevant state authority. Both ensure prompt notification of the incident.
  • Employer’s Injury Report - This document provides detailed information about workplace injuries, paralleling the Alabama First Report form in collecting personal and incident details.
  • Incident Report Form - Used to investigate and document workplace incidents, it complements the Alabama form by detailing circumstances and causes surrounding injuries.
  • Employee Incident Report - Employees may fill out this form to describe what happened during an accident. Similar to the Alabama First Report, it gathers employee accounts of workplace injuries.
  • First Aid Treatment Record - This record is used for injuries treated on-site. It serves a similar purpose in documenting treatment steps taken, akin to the treatment sections of the Alabama First Report.
  • Workers' Compensation Claims Form (Federal) - This federal form outlines the essential details for claims, just as the Alabama First Report serves state-level reporting needs.
  • Healthcare Provider's Report - It documents the treatment provided to an injured employee, similar in purpose to the Alabama form’s requirement for medical treatment details.
  • Accident Investigation Report - This report analyzes the causes of accidents and injuries in the workplace. It works alongside the Alabama First Report in understanding the incident's background.
  • Return-to-Work Form - This document assesses an employee’s readiness to resume work. It mirrors the return-to-work question found in the Alabama First Report.

Dos and Don'ts

When filling out the Alabama First Report form, it’s important to ensure accuracy and completeness. Here’s a guide on what to do and what not to do:

  • Do double-check all information before submission to avoid errors.
  • Do ensure that all required fields are filled out completely.
  • Do accurately describe the incident, detailing what the employee was doing at the time.
  • Do use correct coding for Nature of Injury, Part of Body affected, and Cause of Injury.
  • Do provide the correct dates, especially for injury, notification, and treatment.
  • Don't leave any sections blank unless explicitly stated that they are optional.
  • Don't abbreviate or use unclear terms that may confuse the reader.
  • Don't submit the form without a thorough review of all information.
  • Don't forget to include contact information for both the employee and the employer.

Misconceptions

Understanding the Alabama First Report form is essential for both employers and employees involved in workplace injuries or occupational diseases. However, several misconceptions exist surrounding this form. The following list addresses these misconceptions and provides clarifications based on the Alabama Workmen’s Compensation Law.

  • Misconception 1: The Alabama First Report form is optional.
  • This form is not optional; it is a requirement under the Alabama Workmen’s Compensation Law. Timely submission of this report ensures compliance with legal obligations and facilitates the claims process for injured employees.

  • Misconception 2: Only large employers need to file the form.
  • All employers, regardless of size, must complete and file the Alabama First Report form if an employee suffers an injury or occupational disease while at work. This includes small businesses or sole proprietorships.

  • Misconception 3: The form can be submitted at any time after an injury occurs.
  • The Alabama First Report form must be submitted within a specific time frame following an injury. Delays in reporting can negatively impact the claims process and may lead to complications in receiving benefits.

  • Misconception 4: Providing incorrect information on the form does not matter.
  • Accuracy is crucial when completing the Alabama First Report form. Inaccurate or incomplete information can lead to delays in processing the claim and may result in denial of benefits for the injured employee.

  • Misconception 5: The information on the form is confidential and cannot be accessed by anyone.
  • While certain aspects of the information may be protected under privacy laws, the Alabama First Report form is a public record. Certain parties, including employers, insurers, and potentially other claimants, may access the information for legitimate purposes.

Key takeaways

  • Timeliness is Crucial: The Alabama First Report form must be filed promptly after an injury or occupational disease occurs. Delays can affect the employee’s ability to receive benefits.
  • Accuracy is Essential: Ensure all fields are filled out correctly. Any inaccuracies may lead to complications in processing claims or delays in providing medical care.
  • Provide Detailed Descriptions: When describing the incident, clarity matters. Detail the circumstances surrounding the incident, including what the employee was doing and how the injury occurred.
  • Know the Required Information: Gather necessary information in advance, such as the injured employee’s personal details, details of their employment, and specifics about the injury and treatment. This preparation can streamline the filing process.