MAIL TO: STATE OF ALABAMA Workers’ Compensation Division Department of Industrial Relations Montgomery, Alabama 36131 1(800)528-5166, fax (334)353-0840 E-Mail: Earlene.Mcclease@dir.alabama.gov COMBINATION SUPPLEMENTARY & CLAIM SUMMARY FORM 1. Employee: 2. Social Security number: 3. Employer: 4. Unemployment Compensation Number: 5. Date of Injury: 6. Date disability began this period: 7. Insurance carrier: 8. Claim # 9. Service Co # 10. Name, address and telephone number of office filing this report: SUPPLEMENTAL REPORT FIRST PAYMENT REINSTATEMENT AMENDED A. 1. On the amount of $ was paid for the period from thru (Date of 1st check) Average Weekly Wage 2. 3. Type of Disability: Temporary Total ; $ Compensation Rate Temporary Partial ; $ Permanent Partial per week. ; Permanent Total ; Fatal If periodic payments were awarded by Circuit Court, give name, location and civil action (CV) number and explain: B. COMPENSATION WAS NOT PAID WITHIN 30 DAYS FROM THE DATE OF DISABILITY BEGAN, COMPLETE THIS SECTION. 4. Reason for non-payment: Medical Only , no lost time (return to work date) 5. Under investigation , reason for prolonged investigation In litigation , Under appeal Has compensation been denied and claimant notified? Yes No Reason ? CLAIM SUMMARY FORM SUSPENSION SETTLEMENT AMENDED (DO NOT INCLUDE ANY PAYMENTS PREVIOUSLY FILED ON A CLAIM SUMMARY FORM) 1. 2. Last day comp was owed and paid 3. 4. AWW $ CR (66.7%) $ Amount and type of comp paid: TTD $ WKS TPD $ WKS PPD $ WKS PTD $ WKS Death $ WKS Estate Payment $ Burial Payment LSP $ Date Pd % Part of Body 5. RTW Did claimant work during this period of disability? Ombudsman Yes Date No Yes No Court CV# MMI If so, from total days to Days Days Days Days $ % POB WKS Days Location (County) Adjuster & Title Signature 02/15/2001 American LegalNet, Inc. www.FormsWorkFlow.com