THE USE OF THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE ALABAMA WORKMEN’S COMPENSATION LAW 
 WCC Form 2 
 Rev. 10/2012                                                                                        STATE 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?                          
                                                                                                                                                            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                           
 Emergency Room                                   Hospitalized Overnight                             69. Address               
 Hospitalized > 24 Hours                          Outpatient Treatment                         70. City                                                          71. State                                  72. Zip                                              
 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