Start a Report of Injury or Illness

An ARC claims representative will telephone or email the report preparer to collect additional information necessary to complete this injury or illness report.

EMPLOYER INFORMATION
Employer Business (doing business as) name
Employer Corporate (legal) name*
Mailing Address*
Physical Address
City, State, Zip*
City, State, Zip
INJURED EMPLOYEE INFORMATION
Employee First Name*
Middle Initial
Last Name*
Mailing Address
Occupation Description/Job Title*
City, State, Zip
Gender*
Martial Status
Phone
INJURY/TREATMENT
Date of Injury/Accident*
MM slash DD slash YYYY
Time of Injury/Accident*
Fatality?*
If yes, please provide date of death:
MM slash DD slash YYYY
Injury Occurred on Employer's Premises?*
If No, Accident Site Description i.e. "Customer's House"
Accident Site Address
Description of what the employee was doing just before/when the incident occurred and the injury that occurred, including the body part injured*
Medical Treatment Received?
Name of Facility where treatment was received
Name of Physician or Health Care Professional
Has injured returned to work?*
If yes, date returned to work:
MM slash DD slash YYYY
FORM COMPLETED BY
Date Prepared (Date of submission)*
MM slash DD slash YYYY
Preparer's First Name*
Preparer's Last Name*
Job Title*
Preparer's Phone Number*
Preparer's Email*
Email
This field is for validation purposes and should be left unchanged.

Alabama Retail Association

A Content Site

What is Alabama Retail Comp?

The greatest benefit of Alabama Retail Association membership is the workers’ compensation coverage you can choose to take advantage of through the association’s affiliate, Alabama Retail Comp.