Free 07-6111 - Alaska

ALASKA DEPARTMENT OF LABOR Alaska Workers' Compensation Board P.O. Box 25512 Juneau, Alaska 99802-5512

AWCB Case Number

Petition
(Do Not Use As A Claim for Benefits)

To the Person Receiving this Petition: You have 20 days after the date this petition was mailed or hand delivered to you to respond in writing or ask for a hearing before the Alaska Workers' Compensation Board (AWCB). Your response to this petition must be mailed or hand delivered to the AWCB, and it must show that a copy was given to the person who submitted this petition (See #41 below). If you have an attorney and you have questions, contact your attorney. If you do not have an attorney and you have questions, contact the AWCB.
1. Employee's Name (Last, First, Middle Initial) 2. Insurer Claim No. 3. Date of Injury

4. Address

5. Social Security Number

City

State

Zip Code

Telephone

6. Date of Birth

7. Employer

8. Insurer

9. Address

10. Address

City

State

Zip Code

Telephone

City

State

Zip Code

Telephone

REASON FOR PETITION--CHECK APPROPRIATE BOXES AND COMPLETE QUESTIONS IN DETAIL.

o JOIN ADDITIONAL EMPLOYER(S) AND/OR INSURER(S) (IF ALL ITEMS ARE NOT COMPLETED, THE PETITION WILL BE RETURNED):
11. Name of Employer to be Joined 12. Insurer 13. Address 14. Address

City

State

Zip Code

Telephone

City

State

Zip Code

Telephone

15. Dates Injured Employee Worked for Employer to be Joined

16. Dates of Coverage (Use when joining only insurer) FROM TO

17. Date of Alleged Injury

18. Nature of Alleged Injury

19. Name of Employer to be Joined

20. Insurer

21. Address

22. Address

City

State

Zip Code

Telephone

City

State

Zip Code

Telephone

23. Dates Injured Employee Worked for Employer to be Joined

24. Dates of Coverage (Use when joining only insurer) FROM TO

25. Date of Alleged Injury

26. Nature of Alleged Injury

If more than two employers and/or insurers to be joined, attach additional page and provide above information for each employer and/or insurer.
Form 07-6111 (Rev. 10/95)

CONTINUED ON BACK

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27. Employee's Name (Last, First, Middle Initial)

28. Date of Injury

29. AWCB Case No.

30. Employer

31. Insurer

o PETITION TO TERMINATE BENEFITS (CHECK TYPE TO BE TERMINATED):
32. o Temporary Total Disability o Other 33. Reason for Termination: o Temporary Partial Disability

o Permanent Partial Impairment

o Permanent Total Disability

o Medical Benefits

34.

o

We seek termination of temporary compensation and allege the disability is permanent. A Compensation Report (Form 07-6104, 07-6104A or 07-6104B) showing all compensation paid to date is attached.

35. Date Disability Became Permanent

physician under AS 23.30.095(k). o Examination by Board-selected name, nature of dispute, and dates(State details--Employee's attending physician's name and Insurer's physician's of reports which reflect doctors' disputes.)

o OTHER (STATE IN DETAIL BELOW; ATTACH ADDITIONAL PAGE IF NECESSARY):

36.

o

COMPLETE MEDICAL SUMMARY (Form 07-6103) AND ATTACH IF REQUIRED UNDER 8 AAC 45.052.

37. PROOF OF SERVICE: I certify that on the date in #43 below I mailed or hand-delivered a true and correct copy of this petition (front and back) to the following (your petition will be returned if you do not show service to all parties and employers/insurers sought to be joined): a. o The employee in #1 at the address in #4. c. o The insurer in #8 at the address in #10. e. o The insurer in #12 at the address in #14. g. o The insurer in #20 at the adress in #22. NAME ________________________________________________________________ b. o d. o f. o h. o The employer in #7 at the address in #9. The employer in #11 at the address in #13. The employer in #19 at the address in #21. Other (State name and address):

ADDRESS ___________________________________________________________

NAME ________________________________________________________________

ADDRESS ___________________________________________________________

FORM WILL BE RETURNED UNLESS SIGNED BELOW
38. Attorney's Name and Firm Name (If Represented) 39. Telephone

40. Attorney's Address

City

State

Zip Code

41. Name of Individual Submitting this Form (Print or Type)

42. Signature

43. Date

44. Address

City

State

Zip Code

Form 07-6111 (Rev. 10/95)(BACK)

MAIL TO ALASKA WORKERS' COMPENSATION BOARD

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