ARC Alabama Claims Kit
Download our complete ARC Claims Kit to get claim documents, forms, and notices for the state of Alabama. Employers can request a printed copy of our Claims Kit by contacting us at (800) 239-5423 or support@alabamaretail.org.
State Required Posters and Forms
Please post the following forms and notices in a conspicuous place or places where notices to employees are customarily posted. If you have multiple workplace locations, please be sure to post the notices at each workplace location.
Accident-Injury Forms
The following forms should be completed and submitted to ARC when a work-related accident or injury occurs.
Employer Report of Injury Form
Complete and submit the Report of Injury form as soon as you are notified of the accident/injury. If you suspect the claim is potentially fraudulent, the Report of Injury form should be completed and submitted. Fatalities or accidents involving severe injury should be reported immediately by phone to (800) 239-5423. Keep a copy of the completed form for your records.
Notice to Medical Provider – Authorization for Treatment Form
Complete this form and send it with the injured employee to your designated company medical provider following an accident/injury. This form provides your company’s designated medical provider with Alabama Retail Comp’s billing information and approval for basic medical treatment for the injured employee. Keep a copy of the completed form for your records.
Return to Work Form
Send this form with the injured employee to your designated company medical provider following the accident/injury so the medical provider can address the injured employee’s work status as it pertains to the work-related accident/injury. This form provides your company’s designated medical provider with an outline of the information that is needed for ARC to determine the employee’s work status. Return the completed form to ARC and keep a copy for your records.
Accident Investigation Report
This basic accident investigation form should be completed by the injured employee’s manager or supervisor as soon as safely possible after the accident. Please send the completed form to ARC along with the completed Report of Injury form. Keep a copy of the completed form for your records.
Refusal of Medical Treatment Form
This form should be completed by an employee and supervisor following a work-related accident or injury when medical treatment is offered by the employer but the employee refuses to obtain medical treatment as a workers’ compensation benefit. Note: Completion of this form by an injured employee does not prevent the employee from obtaining medical treatment as a workers’ compensation benefit in the future, if the employee later requests such benefit.
First Fill Prescription Medication Form
This form provides information about our Pharmacy Benefit Program and how to locate a First Fill participating pharmacy. Print and complete this form to provide to your injured employee. The injured employee can provide the completed form along with the prescription for his or her work-related injury to the pharmacy. Utilizing our First Fill Program will expedite the authorization of your employee’s medications and prevent out-of-pocket expenses to you or your employee.
Employee Wage Statement
Complete this form and submit it to ARC within 14 days after your knowledge of any accident or injury that may cause your employee to be disabled for more than 3 scheduled work days. This form is needed to correctly calculate the employee’s compensation benefits that may be owed to your injured employee. Keep a copy of the completed form for your records.
Additional Forms
Claims Reporting Flyer (Management)
This informational flyer can be provided to managers and supervisors at each workplace to post in management offices or for use in management training on how to report workplace accidents or injuries.
Reporting Work-Related Injuries Flyer (Employees)
This informational poster can be provided to managers and supervisors at each workplace to post in a conspicuous location where employees frequent or for use in employee training on how to report workplace accidents or injuries.
