Free ALASKA DEPARTMENT OF LABOR - Alaska

ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Alaska Workers' Compensation Division P.O. Box 115512 Juneau, AK 99811-5512

AWCB Case Number:

WORKERS' COMPENSATION CLAIM
1. Employee's Name (Last, First, Middle Initial) 4. Address City State Zip Code Telephone 2. Insurer Claim Number 5. City/Town/Village Where Injury Occurred 7. Occupation 10. Insurer/Adjusting Company 12. Address State Zip Code Telephone City State Zip Code Telephone 3. Injury Date 6. Social Security Number

8. Date of Birth

9. Employer at Time of Injury 11. Address City

13. Describe how the injury or illness happened:

14. Part of Body Injured

Right

Left

15. Nature of injury or illness:

16. Full name and address of attending physician(s):

17. Reason for filing claim (be specific):

18. This claim amends a prior claim dated

CONTINUED ON BACK

07-6106 (Revised 5/06)

WORKERS' COMPENSATION CLAIM (Continued from Front)
19. Employee's Name (Last, First, Middle Initial) 22. Employer 24. CLAIM IS MADE FOR a. Temporary Total Disability From Through 20. Date of Injury 23. Insurer/Adjusting Company 21. AWCB Case No.

Medical Costs (state amount requested) i. Penalty (state amount requested) $ $ f. Transportation Costs (state amount requested) j. Interest From Through $ $ g. Review of Reemployment Benefit Decision k. Unfair or frivolous controvert (denial) From Through (1) Eligibility (2) Plan Review b. Temporary Partial Disability l. Attorney's Fees and Costs (3) Employee Cooperation From Through $ (4) Other (Give details and amount requested c. Permanent Total Disability m. Death Benefits in #17 above) From Through d. Permanent Partial Impairment h. Compensation Rate (Gross Weekly Earnings) n. Other (Give details and amount Complete to #25 below requested in #17 above) 25. COMPLETE ONLY IF YOU CHECKED 24(h) ABOVE (Compensation Rate). ATTACH EARNING RECORDS AS INDICATED At the time of injury, Employee was a seasonal or temporary worker. (Attach copies of earnings documents for all work during the previous 12 months prior to the injury). b. Employee's earnings were calculated by the day, hour, or output. (Attach copies of documents showing wages from all occupations during either of the two calendar years immediately preceding the injury, whichever is most favorable to the employee.) c. Employee's earnings were calculated by the: Week Month Year (Attach copies of documents evidencing your rate of pay.) Employee's wages had not been set or cannot be determined (Attach information about the usual wage for similar services). d. e. Employee was employed by two or more employers (Attach copies of earning records from all employers). Employee was a minor, apprentice, or trainee in a formal training program. f. g. Employee was injured working as a volunteer ambulance attendant, volunteer medical technician, or volunteer fire fighter. Employee was injured before November 7, 2005 h. 1. Employee was employed less than 13 weeks immediately before the injury. (Attach copies of documents showing what employee would have earned, including overtime and premium pay, if employed for 13 calendar weeks immediately before injury.) 2. Employee was employed 13 calendar weeks or more immediately before the injury. (Attach copies of earning records showing employee's most favorable earnings for 13 consecutive calendar weeks within the 52 weeks immediately before injury.) i. Other a. 26. TO BE USED IN DEATH CASES ONLY. It is claimed the deceased left the following beneficiaries: a. Name b. Age c. Relationship d. Address

e.

27. Applicant's Name (if other than employee) 29. Applicant's Address FORM WILL BE RETURNED UNLESS SIGNED BELOW 30. Attorney's Name (if represented) 32. Attorney's Address 33. Name of individual Submitting the Form (print or type) 36. Address City 34. Signature City State State City State

28. Telephone Zip Code

31. Telephone Zip Code 35. Date Zip Code

MAIL TO WORKERS' COMPENSATION DIVISION

07-6106 (Revised 5/06)