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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
 Supervisor Email



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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