The Sheffield Group



STATE OF ALABAMAEMPLOYER’S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASEEMAIL COMPLETED FORM TO NEWCLAIM@ OR FAX TO 205-991-7978CLAIM REFERENCEFEDERAL TAX ID NUMBER (REQUIRED): INSURED POLICY NUMBER: EMPLOYEREmployer Business Name: FORMTEXT ????Physical Address 1: FORMTEXT ????? Physical Address 2: FORMTEXT ????? City: FORMTEXT ????? State: FORMTEXT ????? Zip: FORMTEXT ????? ADDRESS, IF LOCATION DIFFERENT FROM BUSINESS ADDRESS:Mailing Address 1: FORMTEXT ????? Mailing Address 2: FORMTEXT ????? City: FORMTEXT ????? State: FORMTEXT ????? Zip: FORMTEXT ?????INSURER / FILING OFFICEInsurer Name: Sheffield Risk ManagementMailing Address: 900 Corporate DriveCity: Birmingham State: AL Zip: 35242Filing Office Phone Number: (205) 991-7552Filing Office Fax Number: (205) 991-7978Email report to: newclaim@ EMPLOYEE / WAGESFirst Name: FORMTEXT ????Middle Name: FORMTEXT ????Last Name: FORMTEXT ????Last Name Suffix: FORMTEXT ????EMPLOYEE SSN: FORMTEXT ????? DATE OF BIRTH: FORMTEXT ?????Mailing Address 1: FORMTEXT ????? Mailing Address 2: FORMTEXT ????? City: FORMTEXT ????? State: FORMTEXT ???? Zip: FORMTEXT ????? 39. Phone: FORMTEXT ????? Gender:Male FORMCHECKBOX Female FORMCHECKBOX Date of Hire: FORMTEXT ?????Marital Status:Single FORMCHECKBOX Divorced FORMCHECKBOX Widowed FORMCHECKBOX Unmarried FORMCHECKBOX Married FORMCHECKBOX Separated FORMCHECKBOX Unknown FORMCHECKBOX Nbr of Dependents: FORMTEXT ????? Occupation Description: FORMTEXT ???? # of Days Worked Per Week: FORMTEXT ????? Wages: $ FORMTEXT ????? # of Hours Worked Per Week: FORMTEXT ?????Hourly FORMCHECKBOX Daily FORMCHECKBOX Weekly FORMCHECKBOX Bi-weekly FORMCHECKBOX Monthly FORMCHECKBOX Received Full Pay For Day of Injury? Yes FORMCHECKBOX No FORMCHECKBOX Did Salary Continue After Incident? Yes FORMCHECKBOX No FORMCHECKBOX INJURY / TREATMENTDATE OF INJURY: FORMTEXT ?????Time of Injury: FORMTEXT ????? a.m. FORMCHECKBOX p.m. FORMCHECKBOX unk FORMCHECKBOX Time Employee Began Work: FORMTEXT ????? a.m. FORMCHECKBOX p.m. FORMCHECKBOX Date Disability Began: FORMTEXT ?????Date of Death: FORMTEXT ??? PLACE OF ACCIDENT, INJURY, OR EXPOSURE:Site Address: FORMTEXT ????? City: FORMTEXT ????? State: FORMTEXT ????? Zip: FORMTEXT ????? County: FORMTEXT ????? Injury Occurred on Employer’s Premises? Yes FORMCHECKBOX No FORMCHECKBOX Date Employer Notified: FORMTEXT ?????DESCRIBE IN DETAIL WHAT THE EMPLOYEE WAS DOING JUST BEFORE THE INCIDENT, HOW THE INJURY OCCURRED AND BODY PARTS AFFECTED: FORMTEXT ????? FORMTEXT ????? Initial Treatment:1828800-726948000No Medical Treatment FORMCHECKBOX First Aid By Employer FORMCHECKBOX Minor Clinic FORMCHECKBOX Emergency Room FORMCHECKBOX Hospitalized > 24 Hours FORMCHECKBOX Name of Treatment Facility/Physician: FORMTEXT ????? FORMTEXT ????? Address: FORMTEXT ????? City: FORMTEXT ????? State: FORMTEXT ????? Zip: FORMTEXT ????? Has Injured Returned to Work? Yes FORMCHECKBOX No FORMCHECKBOX Date Injured Returned to Work: FORMTEXT ?????OTHERDate Prepared: FORMTEXT ????? Preparer’s First Name: Last Name: Title: FORMTEXT ???? FORMTEXT ???? FORMTEXT ????Preparer’s Phone: FORMTEXT ?????Preparer’s Fax: FORMTEXT ?????Preparer’s E-mail: FORMTEXT ????? 8/17/18 ................
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