Wcc Form 2 - Employer'S First Report Of Injury Or Occupational Disease
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1THE USE OF THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE ALABAMA WORKMEN’S COMPENSATION LAW
WCC Form 2
STATE OF ALABAMA
Rev. 10/2012
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
ADDRESS, IF LOCATION DIFFERENT FROM BUSINESS ADDRESS
4. Employer Business Name
Southeast Personnel Leasing, Inc. & Subsid
10. Mailing Address 1
5. Physical Address 1
2739 US HWY 19 N
11. Mailing Address 2
6. Physical Address 2
12. City
13. State
14. Zip
7. City
8. State
9. Zip
34691
Holiday
fl
15. Federal ID Number
16. U.C. Account Number
17. NAICS
59-3565930
INSURER / FILING OFFICE
18. Insurer Name
21. Filing Office Name
Lion Insurance Company
22. Mailing Address 1
2739 US HWY 19 N
19. Insurer Federal ID Number
23. Mailing Address 2 or Telephone Number
59-3565930
24. City
25. State
26. Zip
HOLIDAY
FL
34691
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
SSN
Passport Number
Green Card
30. Last Name
Employment Visa
Assigned by Jurisdiction
31 Last Name Suffix (ie. Jr., Sr., III)
34. Mailing Address 1
41. Date of Birth
40. Gender
Male
35. Mailing Address 2
Female
42.Nbr of Dependents
36. City
37. State
38. Zip
39. Phone
43. Marital Status
44. Date Hired
Unmarried (Single or Divorced or Widowed)
Married
Separated
Unknown
46. Number of Days Worked Per Week
45. Occupation Description
49. Received Full Pay For Day of Injury?
Yes
No
47. Wages $
50. Did Salary Continue?
Yes
No
48. Hourly
Daily
Weekly
Bi-weekly
Monthly
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?
Yes
No
56. Site Address
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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