WC Supplementary Report WC Form 3
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State: Alabama Category: Claims Format: PDF Form Name: wc_supp_report.pdf |
(The pdf reader is necessary.) |
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INSTRUCTIONS: ALABAMA SUPPLEMENTARY REPORT (WC Form 3)
Alabama employers are required to file a WC Form 3 whenever payment is made to a worker injured on the job. This document can be found on the website of the Alabama Department of Labor.
Alabama Supplementary Report WC 3 Step 1: Indicate with a check mark if this report documents a first payment, a reinstatement, or is an amended report.
Alabama Supplementary Report WC 3 Step 2: On line 1, enter the name of the employee. On line 2, enter their Social Security number.
Alabama Supplementary Report WC 3 Step 3: On line 3, enter the name of the employer. On line 4, enter their unemployment compensation number.
Alabama Supplementary Report WC 3 Step 4: On line 5, enter the date on which the injury occurred.
Alabama Supplementary Report WC 3 Step 5: On line 6, enter the date in this period on which the disability began.
Alabama Supplementary Report WC 3 Step 6: On line 7, enter the name of your insurance carrier.
Alabama Supplementary Report WC 3 Step 7: On line 8, enter your claim and service company numbers.
Alabama Supplementary Report WC 3 Step 8: On line 9, provide the name, address and telephone number of the officer completing this report.
Alabama Supplementary Report WC 3 Step 9: On line 10, enter the date on which the first check was cut, the amount, and the dates for which it was paid. Also enter the worker's average weekly wage and compensation rate per week.
Alabama Supplementary Report WC 3 Step 10: On line 11, indicate with a check mark if the disability was temporary total, temporary partial, permanent partial, permanent total, or if the incident resulted in a fatality.
Alabama Supplementary Report WC 3 Step 11: If periodic payments were awarded by a circuit court, enter its name and location and the civil action number on line 12.
Alabama Supplementary Report WC 3 Step 12: If payment was not made within 30 days from the date the disability began, explain why on line 13.
Alabama Supplementary Report WC 3 Step 13: If compensation was denied and the claimant was notified, note this on line 14 and explain why.
Alabama Supplementary Report WC 3 Step 14: Sign and date the form, as well as providing your title. |
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