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The Alabama First Report form serves as a crucial instrument within the realm of workers' compensation, ensuring that all relevant parties are well-informed about workplace injuries and occupational diseases. Designed under the provisions of the Alabama Workmen’s Compensation Law, this form must be completed and submitted by employers when an employee suffers an injury or illness related to their work. It includes essential fields such as the employee's personal information, details about the employer, and specifics concerning the nature and circumstances of the injury. Notably, employers must report the date and time of the incident, the location, and a detailed account of what the employee was doing prior to the injury. The form also requires codes to classify the nature of the injury and its cause, facilitating accurate tracking and analysis. Additionally, information about the injured employee's treatment, including the name of the healthcare provider and whether or not the employee has returned to work, is crucial for assessing follow-up care and possible compensation claims. Compliance with this formal reporting requirement not only aids in administrative efficiency but also ensures that employees receive appropriate benefits and protections following workplace injuries.

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

Form Characteristics

Fact Name Description
Mandatory Usage The Alabama First Report form is required for all reports of work-related injuries or occupational diseases under the Alabama Workmen’s Compensation Law.
Identification Numbers This form includes important identifiers such as the Insurer Federal ID Number and the Employer’s Federal ID Number, ensuring accountability and proper tracking.
Employee Information Essential details about the injured employee, including name, address, date of birth, and social security number, must be provided on the form.
Injury Details Sections of the form require a description of the injury, including the nature and part of the body affected, along with how the injury occurred.
Filing Timeline The employer must notify the relevant party of the injury within a specific time frame, highlighting the importance of timely reporting in the claims process.
Treatment Information It is necessary to indicate the initial treatment received by the employee, which can range from first aid to hospitalization, ensuring proper documentation of care provided.

Guidelines on Utilizing Alabama First Report

Once the Alabama First Report form is filled out completely, it needs to be submitted to the appropriate office as per Alabama's Workmen’s Compensation Law. This allows for proper tracking and assessment of the injury or occupational disease claim. Following these instructions will help ensure that you gather all necessary information and complete the form accurately.

  1. Start with the Claim Reference section. Fill in the Insured Report Number, Filing Office Claim Number, and OSHA Log Case Number.
  2. In the Employer section, provide the Employer Business Name. If the location differs, include the Physical Address and Mailing Address. Ensure to list the City, State, and Zip for both addresses.
  3. Next, input the Federal ID Number, U.C. Account Number, and NAICS (if applicable).
  4. In the Insurer / Filing Office section, detail the Insurer Name and include the Insurer Federal ID Number. Select the type of insurer (Insurance Company, Self-Insurer, or Group Fund) and provide corresponding Mailing Address, City, State, and Zip.
  5. For the Employee / Wages section, fill in the employee's First Name, Middle Name, Last Name, and Last Name Suffix. Then include the Employee ID Number, and indicate the type (SSN, Passport Number, Green Card, etc.).
  6. Complete the employee's Mailing Address, along with the City, State, and Zip. Add the employee’s Phone Number, Gender, Date of Birth, Number of Dependents, and Marital Status.
  7. Document the Date Hired, Occupation Description, Number of Days Worked Per Week, and Wages. Determine whether the employee received full pay for the day of the injury and if their salary continued during recovery.
  8. In the Injury / Treatment section, enter the Date and Time of Injury, Time the Employee Began Work, Date Disability Began, and Date of Death (if applicable).
  9. Indicate if the Injury Occurred on the Employer’s Premises. Fill out the Site Address, City, State, Zip, and County.
  10. Clearly describe the employee's activity just before the incident and explain how the injury occurred.
  11. Provide Description Codes for the Nature of Injury, Part of Body affected, and Cause of Injury. Refer to the given website for the appropriate codes.
  12. Identify the Initial Treatment received and the name of the treatment facility or healthcare professional. Indicate if the injured returned to work and provide the corresponding date and time.
  13. Finally, in the Other section, include the Date Prepared, Preparer’s First and Last Name, Title, and Telephone Number.

What You Should Know About This Form

What is the Alabama First Report form?

The Alabama First Report form, also known as WCC Form 2, is a required document under Alabama Workmen’s Compensation Law. Employers must complete this form when an employee is injured on the job or contracts an occupational disease. It serves as the initial notification to the workers' compensation insurer and sets the process for claims and benefits in motion.

Who needs to fill out the Alabama First Report form?

The form must be completed by the employer. This includes any business, organization, or entity that has hired the employee who was injured. The employer is responsible for providing accurate and complete information regarding the incident and the affected employee.

When should the form be submitted?

Employers are required to submit the Alabama First Report form as soon as possible, typically within 5 days of the injury or disease diagnosis. Prompt submission helps to ensure that the employee receives timely medical care and benefits.

What information is required on the form?

The form requires several pieces of information, including employer details, employee information, specifics about the injury or disease, and treatment information. Key fields include the employee's name, occupation, date of injury, and a description of how the injury occurred. Also, insurers and filing office details must be included.

Can the form be submitted electronically?

What if the employer fails to file the report on time?

If the employer fails to submit the report within the required timeframe, they may face penalties. Late submission can delay the employee’s access to benefits and could affect the employer's compliance with workers’ compensation regulations.

Is there a code system used in the form?

Yes, the Alabama First Report form requires the use of description codes. These codes help identify the nature of the injury, the part of the body affected, and the cause of the injury. A complete list of codes is available on the Alabama Department of Labor website.

What should be done if there is a change in the employee's condition?

If there is a change in the employee's condition after the report has been submitted, the employer should update the workers' compensation insurer on the new developments. This may involve filing additional reports or providing updated medical information regarding the employee's health status and return-to-work timeline.

Common mistakes

Many individuals encounter difficulties when filling out the Alabama First Report form for a work-related injury. Making mistakes can delay processing time and create unnecessary complications. It is vital to pay close attention to the details while completing the form. Below are common errors that can occur.

One frequent mistake is not providing complete information about the employer. Many people may overlook entering the full employer business name or providing an incorrect physical address. This can lead to confusion in the processing of the report. Employers must be accurately identified to ensure efficient communication and proper claims handling.

Another common error involves incorrectly detailing employee information. It is essential that the first name, last name, and Social Security Number are filled out accurately. Some individuals might make typographical errors or forget to include a middle name. Missing or incorrect information can hinder the ability to confirm the employee's identity, which may delay support and benefits.

Participants often struggle with the section on describing the injury. Providing a clear and detailed account is crucial. Many reports lack specifics about what the employee was doing just before the injury occurred. A vague description can lead to misunderstandings, possibly affecting the outcome of the claim. Including relevant details can help clarify the situation and ensure that it is properly documented.

Finally, failing to follow up on the date prepared and preparer's information can lead to issues. The preparer’s name and contact number are essential for facilitating communication. Incomplete or missing details can result in delays in processing the claim or difficulty in reaching the correct contact person for further questions. Being diligent about these areas ensures that the report moves forward smoothly.

Documents used along the form

The Alabama First Report form is a crucial document for reporting workplace injuries and occupational diseases in Alabama. When filing this report, you'll often encounter several other forms and documents that work together to complete the claims process. Here are some of the most important ones:

  • Alabama Workmen's Compensation Claim Form: This form is used by employees to formally submit a claim for workers' compensation benefits. It provides detailed information about the injury and sought benefits.
  • Medical Authorization Form: This document allows the employee to give permission for their medical provider to share information with the employer or insurance company. It is essential for processing claims related to medical treatments.
  • Employer's Report of Injury: Often completed by the employer, this form details the circumstances surrounding the injury. It provides context for insurance companies and claims processors.
  • OSHA Incident Report: In cases where an injury may have safety implications, the Occupational Safety and Health Administration’s incident report may be required. This documentation focuses on workplace safety conditions.

Each of these forms plays an important role in ensuring that all parties are informed and that the claims process runs smoothly. Proper documentation helps protect the rights of both employees and employers while facilitating necessary benefits.

Similar forms

  • California Employee Claim Form (DWC 1): Similar to the Alabama First Report form, this document is also used to report workplace injuries. It collects crucial details about the injured employee, the injury itself, and other necessary information, helping both employers and insurers process claims efficiently.
  • New York Workers’ Compensation Board (WCB) Form 1: Much like Alabama's form, the WCB Form 1 serves to document workplace injuries and the pertinent details associated with them. It includes employee information, injury details, and employer notifications, ensuring all parties are informed and responsibilities are outlined.
  • Florida Employee’s Notice of Injury: This form acts similarly to the Alabama First Report by providing a structured way to notify relevant parties about an employee's injury. It details the circumstances of the injury, allowing for a clear understanding of what occurred and the steps necessary for handling the claim.
  • Texas Report of Injury (DWC Form-1): Like the Alabama form, the Texas Report captures important information regarding workplace injuries. It includes specifics on the employee, injury location, and treatment initiated, ensuring that all necessary facts are available for a successful claim review.
  • Ohio Bureau of Workers' Compensation (BWC) Injury Report: Similarly, this Ohio form is designed to report incidents occurring at the workplace. It collects employee and employer data, along with information about how the injury happened and the potential impact on the employee’s work status.

Dos and Don'ts

When filling out the Alabama First Report form, it's essential to keep specific guidelines in mind. Here’s a helpful list of things to do and avoid:

  • Do: Read the entire form carefully before starting.
  • Do: Provide accurate and complete information for all required fields.
  • Do: Use the most recent version of the form to ensure compliance.
  • Do: Double-check names, dates, and numbers for accuracy.
  • Do: Sign and date the form before submission.
  • Don't: Leave blank spaces; fill in all mandatory fields.
  • Don't: Use abbreviations or jargon that might confuse the reviewer.
  • Don't: Ignore the code requirements for describing the injury.
  • Don't: Submit the form late; ensure it is filed within the specified time frame.
  • Don't: Hesitate to ask for help if unsure about any section.

Misconceptions

Several misconceptions exist regarding the Alabama First Report form, which are important to clarify. Understanding these can help ensure compliance and accurate reporting.

  • It is optional to use the Alabama First Report form. This form is mandatory under Alabama Workmen’s Compensation Law. Employers must complete and submit it for all work-related injuries or occupational diseases.
  • The form only needs to be filled out if an employee dies. This is incorrect. The form must be completed for all injuries, regardless of severity, to ensure proper record-keeping and claims processing.
  • The information collected on the form is not confidential. In fact, the details in the Alabama First Report form are sensitive. Employers must protect this information according to privacy laws and regulations.
  • Filing the form guarantees compensation for the injured employee. Completing the form does not automatically secure benefits. It initiates the claims process, which will be subject to evaluation by the insurer.
  • The form can be filed at any time after an incident. There are deadlines for submitting this report. Employers must ensure timely filing to avoid complications with claims processing.
  • Any employee can complete the form. While other personnel may gather information, the form must be signed and dated by an authorized representative of the employer for it to be valid.

Recognizing these misconceptions can lead to better practices in workplace injury reporting, ensuring that all parties involved understand their roles and responsibilities.

Key takeaways

When filling out the Alabama First Report form, keep these key points in mind:

  • Accurate documentation is crucial. Ensure all employer and employee information is filled out correctly, including names, addresses, and identification numbers.
  • Provide a clear description of the incident. Include what the employee was doing right before the injury and how it occurred. This helps establish the context and nature of the claim.
  • Be specific about the injury details. Use the provided codes for nature of injury, part of body affected, and cause of injury to ensure clarity in processing the report.
  • Timeliness matters. Notify the employer and file the report promptly after the incident to comply with Alabama's workmen’s compensation law.
  • Record follow-up actions. If the injured employee has returned to work, include the date and time, which is important for ongoing records and benefits tracking.