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SEICTF
Supervisor’s First Report of Injury or Occupational Disease


Please complete all sections and submit this report to the Division of Risk Management within 24 hours of the injury. Please also submit the Accident Report – Employee Statement form to 334-223-6170 or 888-827-6753 or via email to SEICTF@finance.alabama.gov. If you need assistance, call 800-388-3406 between 8am and 5pm, Monday thru Friday.
Name of Injured Employee
Last
 

First
 

MI

SSN
(use 999-99-9999 format)
Date of Birth
(use mm/dd/yyyy format)
Sex

Employee Number
 

   
Home Address
No. and Street
City or Town
State
ZIP
Mailing Address
No. and Street
City or Town
State
ZIP
Email

 
Phone
(use 999-999-9999 format)
Work Hours
Home
 
Work
 
Cell
 
From
To
Job Title
Status
Job Code
Normal Scheduled Days Off
          
Employing Agency
Agency Address
No. and Street
City or Town
State
ZIP
Date of Injury
Date Employer Notified
Time of Injury
Is the employee covered by State Employee Medical Insurance?
Has the injury resulted in medical treatment?
Exact Location where injury occurred
(Include street address, building, room, parking lot, etc., if possible)
Was injury caused by a motor vehicle accident?
Was more than one person injured in this accident?
Describe the specific activity the employee was performing at the time the event or exposure occurred and what happened to cause the injury. Indicate the body part(s) affected.
Could this accident have been prevented?
Name all witnesses
Name
Address
Phone
 
Name
Address
Phone
 
Typed Signature:
Daytime Phone



I am the supervisor of the employee making the claim for SEICTF and have filled out this First Report of Injury based on the information that has been reported to me. By checking the box above, I certify that the above information is true and correct to the best of my knowledge. I agree that the typed signature appearing here is the same as and has the same legal effect of my signature as if written herein.

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