Local Education Agency Injury Report

Is employee covered by medical insurance? *
What type of insurance? *
Were there witnesses to the injury? *
Notification to Employee: Any unreimbursed medical expenses and costs which the employee incurs as a result of an on-the-job injury may be filed for reimbursement with the State Board of Adjustment. Reimbursement to the employee shall be determined by the Board of Adjustment’s policies, rules, and regulations which may be adopted from time to time. The Board of Adjustment shall adopt appropriate rules, regulations and forms for submission by the employee. The Statute of Limitations is one year, if death is involved, two years. Claim forms or information may be obtained by contacting: State Board of Adjustment, Alabama State Capitol, Third Floor East Wing, Montgomery, AL 36130-1435. Physical Mailing address: 600 Dexter Avenue, Suite 302, Montgomery, AL 36104
Signature of Injured Person *