ACCIDENT REPORT
EMPLOYEE'S STATEMENT
State Employee Injury Compensation Trust Fund
SEICTF 

This  form  must  be  completed  by  the  employee  and  submitted  to  the  immediate  supervisor  on  the  day  the  injury  occurs.  The 
supervisor  should  submit  the  First  Report  of  Injury  (SEICTF  Form  1)  along  with  this  completed  form  immediately  to  
SEICTF@finance.alabama.gov or via fax to 334-223-6170 or 888-827-6753. 

Date of Injury/Accident 

____________________ 
Today’s Date 

Time of Injury/Accident     
On break or at lunch at the time of accident?  (cid:1)  Yes  (cid:1)  No 

 (circle one) 
 a.m. / p.m. 

Employee Name (Last, first, middle initial) 

Date of Birth 

Social Security Number (Complete SSN not just last four.) 

Street address 

City 

 State 

 Zip Code 

Primary phone number 
Preferred method of contact by SEICTF: (choose one)  (cid:1) Email

Email address 

(cid:1) US Postal Service Mail Delivery

Job Title/Classification Code 
Describe the specific activity you were performing at the time the injury/accident occurred including 
exactly what happened to cause injury/accident.  

Name of Supervisor 

Date Supervisor Notified 

Accident:

Injuries/Body Part(s): 

Exact location where injury/accident occurred:

Were there any witnesses?  (cid:1) Yes

(cid:1) No

If yes, give names, addresses, and phone numbers of each: 

Circle Injured Body Part

Was injury/accident a result of an automobile accident? 

(cid:1) Yes

(cid:1) No

If yes, obtain a copy of the police report of accident and submit to supervisor as soon as possible. 
At the time of the injury/accident, were you using any protective equipment (ex. Latex gloves, eye protection)?  (cid:1)  Yes    (cid:1)  No
If yes, list equipment used: 
Have you previously had pain, treatment, diagnostic testing (x-rays, MRI, etc.) 
(cid:1) Yes
or injury to the same body part(s)?    
If yes, enter body part affected, date(s) of injuries and name(s) and address(es) of treatment provider(s). 

(cid:1) No

I understand the intentional reporting of false information will disqualify me from receiving further SEICTF benefits and could expose 
me to penalties or criminal charges.  I certify all information is correct to the best of my knowledge. 

I further understand that non-compliance with SEICTF Rules (i.e. failure to attend medical appointments as scheduled, failure to respond 
to requests for contact, failure to provide signed medical authorization forms, failure to cooperate with SEICTF staff,  failure to comply 
with your physician’s medical treatment plan, etc.) will progressively lead to suspension and/or termination, per Administrative 
Procedures Act 355-8-1.03(e). 

_________________________________________________________________________ 
Signature of Employee 

________________________________ 
Date 

_______________________________________________ 
Signature of Supervisor reporting incident 

_______________________ 
Date 

________________________________ 
Daytime Phone 

REV 10/21/2015