Fillable Boa On Job Injury Claim (Alabama A&M University)

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Boa On Job Injury Claim (Alabama A&M University)

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The Boa On Job Injury Claim (Alabama A&M University) form is 5 pages long and contains:

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  • 3 check-boxes
  • 98 other fields

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Page 1 of 5
BOA OTJ Injury Form 3/7/2013
INSTRUCTIONS FOR ALABAMA STATE BOARD OF ADJUSTMENT
CLAIM FOR ON THE JOB INJURY
www.bdadj.alabama.gov
NOTE: Claims must be presented to the Alabama State Board of Adjustment within one year after the
date of the injury or within two years for claims for injury resulting in death. Each question must be
answered. If all questions are not answered, the claim will not be accepted. Forms must printed in ink or
typed. All supporting documentation must be submitted on 8 ½ x 11 paper front side only.
******************************************************************************************
Claim forms must be accompanied by all of the required documentation or your claim will be returned
requesting further information. Any delays could cause the dismissal of your claim.
• MAIL COMPLETED FORMS TO
Alabama State Board of Adjustment
:
600 Dexter Avenue, Suite E-302
Montgomery, AL 36104
• FORMS MAY BE DELIVERED TO
Alabama State Board of Adjustment
:
State Capitol Building, Suite E-302
Montgomery, Alabama
• Telephone Numbers: (334) 242-7175 Fax: (334) 242-2008
******************************************************************************************
1. Enter the name of the State Agency you are filing your claim against. (Example: Department of
Transportation, Department of Education, etc.)
2. Enter your personal information. Enter your Name, Address, Telephone Number(s), E-mail Address, the
last four digits of your Social Security Number or the last four digits of your FEIN if a business. Claims
without the last four digits cannot be processed and will be returned to the Claimant.
3. If you have an attorney, enter your attorney’s information. (NOTE: If an attorney is listed, all
correspondence will be with the attorney only.)
4. Enter the facts of the claim
A. Enter the date the injury occurred.
:
B. Enter the date notified by employer of your privilege to file a claim with the Board of Adjustment.
C. Enter the location and address where the injury occurred. (Example: Lunchroom at City Elementary,
City, Alabama 36000)
D. A statement of facts describing the injury and the events surrounding the injury. Documentation must
accompany the claim for proof of the injury. Provide an official accident or incident report showing the
date of the injury. The report must be signed by a supervisor or some other official. Any other evidence to
prove that the incident upon which the claim is based took place must be attached. (Example: Dated and
signed witness statements.)
5. If this was an on-the-job injury, check yes. If no, use Personal Injury Form. This form can be found on the
Board of Adjustment web site shown at the top of this page.
6. Employer Information
A. Enter the name, address and telephone number of your employer.
:
B. Enter your job title at the time of the injury.
C. Enter your supervisor’s name at the time of the injury.
D. If you are still employed with employer listed in 6A check the “Yes” box.
E. If you are no longer employed with employer listed in 6A, enter your last date of employment.
Page 2 of 5
BOA OTJ Injury Form 3/7/2013
Instructions for Alabama State Board of Adjustment
Claim for On The Job Injury
Page 2
7. Medical Expenses
A. Total of Medical Expenses Claimed
: Enter all medical expenses incurred as a result of the injury. Include additional sheets if
necessary. List each health care provider, including pharmacy, and the amount charged by each. You must
provide evidence (itemized bills) to show what treatment was provided, when it was provided, and the
charge, as well as evidence of insurance filing and payments (insurance company summary sheets). Board
of Adjustment will not make awards for expenses paid by private insurance. If claimant is not covered by
insurance, this should be clearly stated.
8. If you had medical insurance at the time of the injury, name all insurance companies and state how much
each paid directly to you.
A. Total Payments Made to You from All Insurance Companies
9. Medical Disability
A. If you are claiming damages for permanent disability, check “Yes”; otherwise, check “No.
: If you are claiming medical disability, you MUST complete this section.
B. If you have claimed compensation for permanent disability from any source, such as Social Security
Disability, Workman’s Compensation, etc., check “Yes”; otherwise, check “No”.
C. Enter the amount you are seeking for permanent or total disability.
D. Describe the permanent disability. Evidence (usually a letter, statement, or report from physician) that
claimant has reached maximum medical improvement “MMI” and is left with a disability stated in
percentage of physical impairment to the whole body or part of body is involved (arm, leg, finger, etc.).
10. Wages
: If you are claiming lost wages and/or compensation for leave used, list each separately. Evidence
from doctor or other healthcare provider that claimant was unable to work because of the accident/injury
stated, verification from the employer of the time lost from work or the leave deducted and verification from
the employer of the claimant’s rate of pay at the time of the accident/injury.
A. Enter the amount of wages you lost due to the injury. Circle whether the amount you have entered is for
hours, days or weeks. (Example: $25 for 2 hours)
B. Enter the amount of leave used. (Example: 16 hours for 2 days)
C. Enter your rate of pay at the time of your injury. Check the box indicating whether the amount is per
hour, day, or week. (Example $12.50 per hour)
D. Enter the total of wages lost due to the injury.
11. Enter any miscellaneous expenses associated with the personal injury, such as damages to automobile,
eyeglasses, mileage, etc. Note: If claiming mileage, use the Mileage Log which is listed on the web site,
www.bdadj.alabama.gov, as Alabama State Board of Adjustment Mileage Log.
A. Provide the total amount of miscellaneous expenses claimed.
B. If any of the listed expenses are covered by insurance, please check “Yes”; otherwise, check “No”.
C. If you answered “Yes” in Item 11.B., list the amount of insurance coverage and your deductible. (For
damages to personal property, it will be necessary to provide a copy of your insurance declaration page
which indicates your amount of coverage and your deductible.)
12. Enter the GRAND TOTAL amount you are claiming for all items described in Items 7.A., 9.C., 10.D., and
11.A.
13. Sign the claim form in the presence of a Notary Public, print your name and have the notary complete the
verification section.
Page 3 of 5
BOA OTJ Injury Form 3/7/2013
ALABAMA STATE BOARD OF ADJUSTMENT
CLAIM FOR PERSONAL INJURY - ON THE JOB
See Page 1-2 of this form for instructions. Each
number on the form corresponds with numbers on
instruction sheets. Read all instructions carefully to
ensure your claim is not returned for additional
supporting documentation.
See INSTRUCTIONS
for mailing or hand delivering this form to the Board
of Adjustment (Page 1).
DO NOT WRITE IN THIS SPACE. FOR BOARD
OF ADJUSTMENT USE ONLY.
Claim No.:_________________________________
1. Name of the Department or Agency of the State of Alabama against which you are making this claim:
_______________________________________________________________________________
2. Claimant’s Information:
Name: _______________________________________________________________________________
Street Address or P.O. Box: ______________________________________________________________
City, State, Zip Code: ___________________________________________________________________
E-mail Address: ________________________________________________________________________
Home Telephone No.: _________________________ Office Telephone No.: _______________________
Cellular Telephone No.: ________________________Fax No.: __________________________________
Claimant’s Last Four Digits of Social Security No. or last four digits of Business FEIN:
SSN: XXX-XX-________ FEIN: XX-XXX ________
3. Claimant’s Attorney: (NOTE: If an attorney is listed, all correspondence will be with the attorney only.)
Attorney Name: ________________________________________________________________________
Street Address of P.O. Box: _______________________________________________________________
City, State, Zip Code: ____________________________________________________________________
E-mail Address: _________________________________________________________________________
Office Telephone No.: __________________________Fax No.: __________________________________
4. Facts of Claim:
A. Date of Injury: _______________________________________________________________________
B. Date notified by employer of your privilege to file a claim with Board of Adjustment:________________
C. Location/Address of Injury: _____________________________________________________________
D. Statement of Facts (Describe the injury and the events surrounding the injury): _____________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
5. Was this an on-the-job injury? Yes No
Page 4 of 5
BOA OTJ Injury Form 3/7/2013
Claimant’s Name___________________________________
6. Employer Information (If on-the-job injury):
A. Name, Address & Telephone Number of Employer: ____________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
B. Job Title at the Time of the Injury: __________________________________________________________
C. Name of Supervisor at the Time of the Injury: _________________________________________________
D. Are you still employed with employer listed in 6.A.? Yes No
E. If no, what was the date of your last day of employment? ________________________________________
7. Medical Expenses (List each health care provider, including pharmacy, and the amount charged by each):
Include additional sheets if necessary:
Provider
Amount of Expense
A. Total of Medical Expenses Claimed: ___________________________________________
8. If you had medical insurance at the time of the injury, name all insurance companies and state how much each
paid directly to you:
Name of Insurance Company
(Includes Medicare, Medicaid)
Amount Paid To You
A. Total Payments Made To You from All Insurance Companies: __________________________________
9. Medical Disability:
A. Are you claiming damages for permanent disability? Yes No
B. Have you claimed compensation for permanent disability for this injury from any other source, such as
Social Security Disability, Workers Compensation, etc.? Yes No
C. What is the amount you are seeking for permanent or total disability? ____________________________
Page 5 of 5
BOA OTJ Injury Form 3/7/2013
Claimant’s Name___________________________________
Medical Disability (Continued)
D. Describe the permanent disability: ________________________________________________________
:
____________________________________________________________________________________
____________________________________________________________________________________
10. Wages (If you are claiming lost wages and/or compensation for leave used, list each separately):
A. Amount of lost wages: ________________ for ____________________________ hours/days/weeks
B. Amount of leave used: _________________ for ___________________________ hours/days/weeks
C. Rate of Pay at time of Injury: ______________ per Hour Day Week
D. Total Wages Claimed: _________________________________________________________________
11. Miscellaneous Expenses: (List other expenses you are claiming and the amount for each such as damages to
auto, eyeglasses, mileage, etc.) If claiming mileage, use the Mileage Log which is listed on the web site,
www.bdadj.alabama.gov, as Alabama State Board of Adjustment Mileage Log.
Item
Amount of Expense
A. Total Amount of Miscellaneous Expenses Claimed: _________________________________________
B. Are any of the expenses listed above covered by insurance? Yes No
C. If yes, list amount of coverage and deductible amount:
Amount of Coverage: ____________________________________________________________________
Comprehensive Deductible: ___________ Collision Deductible: _____________
12. What is the GRAND TOTAL
amount you are claiming for all items described in Items 7.A., 9.C., 10.D., &
11.A.__________________________________________________________________________________
13. Signature of Claimant/Authorized Representative: ________________________________________________
Please Print Name: _________________________________________________________________________
*****************************************************************************************
VERIFICATION
STATE OF ___________________________
COUNTY OF _________________________
Before me, a Notary Public in and for said state and county, personally appeared the person whose name is
signed above who being made known to me and being duly sworn to give true testimony, affirmed that all of the
above stated facts are true and correct.
Sworn and subscribed before me this _____ day of ______________________, 20 _____
Signature of Notary Public _____________________________________________
AFFIX SEAL Printed Name ________________________________________________________
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