The Alabama First Report form serves as a crucial document for reporting workplace injuries or occupational diseases under the Alabama Workmen’s Compensation Law. This form, officially designated as WCC Form 2, must be completed by employers to provide necessary information about the incident, the injured employee, and the circumstances surrounding the injury. Understanding how to accurately fill out this form can help ensure compliance and facilitate the claims process for affected workers.
The Alabama First Report form serves as a crucial document for employers to report workplace injuries or occupational diseases. This form is mandated under the Alabama Workmen’s Compensation Law, ensuring that all relevant information is collected systematically. Key components include the employer's details, such as business name, physical and mailing addresses, and federal identification numbers. Additionally, the form requires specific information about the employee, including their name, contact details, occupation, and wage information. Critical to the reporting process, the form also captures details about the injury itself, including the date, time, and location of the incident, as well as a description of what the employee was doing at the time. Furthermore, it necessitates codes to classify the nature of the injury, the affected body part, and the cause of the injury, which aids in comprehensive data collection for analysis and trend identification. The form also addresses treatment received and the employee's return to work status, providing a complete picture of the incident and its aftermath. By adhering to these reporting requirements, employers can ensure compliance with state regulations while supporting their employees during challenging times.
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?
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
PLACE OF ACCIDENT, INJURY, OR EXPOSURE
61. Injury Occurred on Employer’s Premises?
56.
Site Address
57.
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.
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
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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