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THE USE OF THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE ALABAMA WORKMEN’S COMPENSATION LAW 03/01/2006 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 City of Hoover 5. Physical Address 1 100 Municipal Drive 6. Physical Address 2 7. City Hoover 8. State AL 9. Zip 35216 ADDRESS, IF LOCATION DIFFERENT FROM BUSINESS ADDRESS 10. Mailing Address 1 P. O. Box 360628 11. Mailing Address 2 12. City Hoover 13. State AL 14. Zip 35236 15. Federal ID Number 63-0570405 16. U.C. Account Number 1-3051100 17. NAICS 92 INSURER / FILING OFFICE 18. Insurer Name City of Hoover 19. Insurer Federal ID Number 63-0570405 20. Type Insurer Ins Co Self-Insurer Group Fund 21. Filing Office Name Hill Administrative Services 22. Mailing Address 1 P. O. Box 36067 23. Mailing Address 2 or Telephone Number 24. City Birmingham 25. State AL 26. Zip 35236 27. Filing Office Federal ID Number 63-1257581 EMPLOYEE / WAGES 28. First Name 29. Middle Name 30. Last Name 31 Last Name Suffix (ie. Jr., Sr., III) 32. Employee ID Number 33. Type Employee ID Number SSN Passport Number Green Card Employment Visa Assigned by Jurisdiction 34. Mailing Address 1 35. Mailing Address 2 36. City 37. State 38. Zip 39. Phone 40. Gender Male Female 41. Date of Birth 42.Nbr of Dependents 43. Marital Status Unmarried (Single or Divorced or Widowed) Married Separated Unknown 44. Date Hired 45. Occupation Description 46. Number of Days Worked Per Week 47. Wages $ 48. Hourly Daily Weekly Bi-weekly 49. Received Full Pay For Day of Injury? Yes No 50. Did Salary Continue? Yes No INJURY / TREATMENT 51. Date of Injury 52. Time of Injury a.m. p.m. unk 53. Time Employee Began Work a.m. p.m. 54. Date Disability Began 55. Date of Death PLACE OF ACCIDENT, INJURY, OR EXPOSURE 56. Site Address 57. City 58. State 59. Zip 60. County 61. Injury Occurred on Employer’s Premises? Yes No 62. Date Employer Notified 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 First Aid By Employer Minor Clinic / Hospital Emergency Room Hospitalized Overnight Hospitalized > 24 Hours Outpatient Treatment 68. Name of Treatment Facility 69. Address 70. City 71. State 72. Zip 73. Name of Physician or Other Health Care Professional 74. Has Injured Returned to Work Yes No If so, 75. Date 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