Free Employers' Notice of Insurance - Alaska

EMPLOYER'S NOTICE OF INSURANCE
TO THE EMPLOYEES OF THE UNDERSIGNED:
Your employer is insured by
Insurer Street and Number City State Zip Code

For the period from Adjusting Company Street and Number City State

Through

Zip Code

Telephone

This insurance pays benefits for job-connected injuries, illnesses or death as provided by the Alaska Workers' Compensation Act
Employer By Title Witness Witness

Immediately (not later than 30 days from injury or death date) give your employer and the Alaska Workers' Compensation Division written notice of a job-related injury, illness, or death. Get the "Report of Occupational Injury or Illness" form from your employer for this purpose. If you have questions about your rights or benefits under the Alaska Workers' Compensation Act, contact the insurer at the above address and the Alaska Workers' Compensation Division at the nearest office listed below: ANCHORAGE PO Box 107019 3301 Eagle St Ste 304 Anchorage AK 99510-7019 (907) 269-4980 FAIRBANKS 675 7th Ave Station K Fairbanks AK 99701-4531 (907) 451-2889 JUNEAU PO Box 115512 1111 W 8th St Rm 307 Juneau AK 99811-5512 (907) 465-2790

NOTICE TO EMPLOYER: AS 23.30.060 requires that you post this notice in three conspicuous place on the employer's premises.
Form 07-6120 (Revised 01/2007)