Free P&IFOR~1 - Alaska

REPORT OF VESSEL/SITE INSURANCE

ALASKA DEPARTMENT OF LABOR FISHERMEN'S FUND BOX 21149 JUNEAU, ALASKA 99802-1149

INJURED/ILL FISHERMAN'S NAME

INJURY/ILLNESS

DATE OF INJURY

NAME OF VESSEL OR BEACH SITE permittee
(Please Print Name)

In order to process a claim for Fishermen's Fund benefits, medical insurance coverage information must be provided (8 AAC55.010 (e)). Crewmembers MUST CONTACT THEIR EMPLOYER (vessel or site owner/operator) and advise that it is necessary for them to "fully" complete and sign this report before full Fishermen's Fund benefits can be approved. Until this signed report is received, benefits will be limited to $2,500 in accordance with the Fishermen's Fund Advisory and Appeals Council policy.

OWNER/OPERATOR REPORT OF VESSEL/SITE INSURANCE
Owner/Operator: You must check all boxes ¨ that apply, AND MUST NOTE VESSEL P&I DEDUCTIBLE AND INSURANCE CARRIER I certify, under penalty of perjury, that: 1) ¨ The vessel/site DOES HAVE Protection & Indemnity (P & I) insurance and the: Deductible is Insurance Carrier is Address Phone :$ (must answer as required by 8 AAC 055.010 (e)); : ________________________________ : ________________________________ : ________________________________

¨ A claim HAS BEEN made to the P & I insurance carrier. ¨ A claim has NOT been made to the P & I insurance carrier because:

2) ¨ The vessel DOES NOT HAVE Protection and Indemnity (P & I) insurance or other medical liability coverage. Signed by: /

The Fishermen's Fund is not an insurance program and should not be considered as the Primary payor. Benefits are limited to medical expenses that are not otherwise covered by public or private insurance, 8 AAC 055.010(e).