Free WC Assessment Form (Instructions) - Alabama

WCC10 Alabama Assessment Form Reporting period: January 1 ­ December 31 Mailed 1st week of January Due March 1st Annually
A PENALTY OF $25.00 A DAY WILL BE ASSESSED FOR FORMS RECEIVED AFTER MARCH 1ST Total Compensation: All payments paid to claimant to include TTD, TPD, PPD, and PTD. All payments made to medical providers to include: Hospitals, Doctors, Chiropractors, Home Health, Mileage, Future Medical payments, etc. Utilization Review, Case Management, Fees paid for post accident drug testing, Investigation, etc. Plaintiff Attorney fees, Depositions, Subpoenas, Court Cost, etc. Court Ordered Settlements or Lump Sum Settlements. These settlements may be included in the compensation and/or medical, If so, do not list the settlements again.

Total Medical:

Administrative Expenses:

Legal Expenses:

Court Settlements:

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