Fillable Printable Employer's First Report of Injury or Occupational Disease - Alabama
Fillable Printable Employer's First Report of Injury or Occupational Disease - Alabama
Employer's First Report of Injury or Occupational Disease - Alabama
THE USE OF THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE ALABAMA WORKMEN’S COMPENSATION LAW
03/01/2006
WCC Form 2
Rev. 10/2012
STATE 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
5. Physical Address 1
6. Physical Address 2
7. City 8. State 9. Zip
ADDRESS, IF LOCATION DIFFERENT FROM BUSINESS ADDRESS
10. Mailing Address 1
11. Mailing Address 2
12. City 13. State 14. Zip
15. Federal ID Number
16. U.C. Account Number
17. NAICS
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 26. Zip
27. Filing Office Federal ID Number
EMPLOYEE / WAGES
28. First Name
29. Middle Name
30. Last Name
31 Last Name Suffix (ie. Jr., Sr., III)
32. Employee ID Number
33. Type Employee ID Number
SSN Passport Number Green Card
Employment Visa Assigned by Jurisdiction
34. Mailing Address 1
35. Mailing Address 2
36. City 37. State 38. Zip 39. Phone
40. Gender
Male
Female
41. Date of Birth
42.Nbr of Dependents
43. Marital Status
Unmarried (Single or Divorced or Widowed) Married Separated Unknown
44. Date Hired
45. Occupation Description
46. Number of Days Worked Per Week
47. Wages $
48. Hourly Daily Weekly Bi-weekly Monthly
49. Received Full Pay For Day of Injury? Yes No
50. Did Salary Continue? Yes No
INJURY / TREATMENT
51. Date of Injury
52. Time of Injury
a.m. p.m. unk
53. Time Employee Began Work
a.m. p.m.
54. Date Disability Began
55. Date of Death
PLACE OF ACCIDENT, INJURY, OR EXPOSURE
56. Site Address
57. City 58. State 59. Zip
60. County
61. Injury Occurred on Employer’s Premises?
Yes No
62. Date Employer Notified
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
First Aid By Employer Minor Clinic / Hospital
Emergency Room Hospitalized Overnight
Hospitalized > 24 Hours Outpatient Treatment
68. Name of Treatment Facility
69. Address
70. City 71. State 72. Zip
73. Name of Physician or Other Health Care Professional
74. Has Injured Returned to Work
Yes No
If so, 75. Date
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
