Wcc Form 2 PDF Details

Wcc form 2 is an important document for any worker in the United States. This form is necessary to ensure that both the employer and employee are in compliance with all applicable labor laws. By filling out wcc form 2, each party can be assured that they are meeting all federal requirements. In addition, this form can help protect employers from potential lawsuits. For workers, wcc form 2 is also a valuable tool for understanding your rights and protections under the law. Filling out this form correctly is essential for ensuring safe and lawful employment.

QuestionAnswer
Form NameWcc Form 2
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesstate of alabama first report fillable, 21a, NAICS, Nbr

Form Preview Example

THE USE OF THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE ALABAMA WORKERS’S COMPENSATION LAW

 

WCC FORM 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REV. 9/2006

 

 

 

 

 

 

 

 

STATE OF ALABAMA

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER’S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE

 

 

 

 

 

 

 

 

 

 

 

Ombudsman 1-800-528-5166

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 or Telephone Number

 

 

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

 

 

 

 

 

 

 

 

 

 

21a. Service Co. #

19.

Insurer Federal ID Number

 

 

 

 

 

 

 

22. Mailing Address 1

 

 

 

 

 

 

 

 

 

 

 

 

20.

Type Insurer

 

 

Insurance Co.

Ins Co #

 

 

 

 

23. Mailing Address 2 or Telephone Number

 

 

 

 

 

 

 

 

 

 

 

Self-Insurer

SI #

 

 

 

 

24. City

 

 

 

 

25. State

 

26. Zip

 

 

 

 

 

Group Fund

GF #

 

 

 

 

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

 

 

 

 

 

 

39. Phone

 

 

 

 

Female

 

 

 

 

 

42.Nbr of Dependents

 

 

 

. Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

60. County

 

 

 

 

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:// DIR.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

 

 

 

68. Name of Treatment Facility

 

 

 

 

 

 

 

 

 

Minor Clinic / Hospital

Emergency Room

 

 

 

 

 

69. Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hospitalized > 24 Hours

Major medical/Lost time

 

 

 

70. City

 

 

 

 

 

71. State

 

 

 

72. Zip

 

 

Hospitalized Overnight

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

How to Edit Wcc Form 2 Online for Free

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Step 2: The tool enables you to change PDF documents in many different ways. Enhance it by adding your own text, correct what's originally in the file, and include a signature - all at your disposal!

As for the blank fields of this precise PDF, this is what you should know:

1. To start with, when filling in the WCC, start with the page that features the following fields:

INSURER conclusion process detailed (portion 1)

2. Given that the previous section is done, you're ready add the essential details in PLACE OF ACCIDENT INJURY OR, Injury Occurred on Employers, PROVIDE DESCRIPTION CODES to, FOR COMPLETE LIST OF CODES GO TO, Nature of Injury Code Part of, Name of Treatment Facility, First Aid By Employer Emergency, Has Injured Returned to Work Yes, If so Date Time am, Date Prepared, Preparers First Name Last Name, Preparers Telephone Number, and OTHER so you're able to progress to the next step.

Learn how to fill out INSURER portion 2

People generally make errors while filling out Nature of Injury Code Part of in this area. Don't forget to reread everything you type in right here.

Step 3: Prior to submitting your document, you should make sure that blank fields were filled out the right way. Once you believe it's all good, click “Done." Create a 7-day free trial option with us and gain direct access to WCC - with all transformations saved and available inside your personal cabinet. We do not share the details you use while working with forms at our website.

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