Alabama First Report PDF Details

The Alabama First Report form stands as a critical document under the Alabama Workmen’s Compensation Law, emphasizing the structured protocol for reporting workplace injuries or occupational diseases. This comprehensive form, officially designated as WCC Form 2 Rev. 10/2012, requires detailed information spanning from the employer’s credentials to intricate details of the employee's injury and subsequent treatment. Employers are required to fill out various sections which include, but are not limited to, insured report number, employer and insurer information, employee wage details, and specifics about the injury or disease such as the date, time, and how the incident occurred. Additionally, the form calls for the recording of the initial treatment received, with a provision for indicating the nature of Injury, part of the body affected, and the cause of the injury using specific description codes. This compulsory form serves not only as a record of the incident but also plays a vital role in the process of claims under the workmen’s compensation system in Alabama, ensuring transparent and prompt communication between employers, employees, and insurers regarding workplace injuries or diseases.

QuestionAnswer
Form NameAlabama First Report
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesal form report, wcc form 2, first report of injury form alabama fillable, state of alabama first report of injury form

Form Preview 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

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