Free 07-6104b - Alaska


File Size: 114.9 kB
Pages: 2
Date: September 28, 2000
File Format: PDF
State: Alaska
Category: Workers Compensation
Author: BASCCDS
Word Count: 1,299 Words, 9,275 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.labor.state.ak.us/wc/forms/wc6104b.pdf

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Preview 07-6104b
EMPLOYEE:
AlaskaDepartmentofLaborandWorkforceDevelopment AlaskaWorkersCompensationBoard P.O.Box25512,Juneau,Alaska99802-5512
1. Employees Last Name First Name 4. Address

This report is for your information. Keep it for your records. Read important information about your rights on back.

COMPENSATION REPORT
(FOR INJURY DATES JULY 1, 1988 & AFTER)
Initial 2. Insurer Claim Number

AWCB Case Number Only

3. Injury Date

5a.

p Single p Married

5b. No. of Dependents

6. Social Security Number





City

State

Zip

Telephone

(AWCB use only)

7. Birthdate

8. Employer

9. Insurer/Adjusting Company

10. Address

11. Address

City

State

Zip

Telephone

City

State

Zip

Telephone

12. p p p p p p

COMPENSATION RATECOMPLETE FOR INITIAL PAYMENT OR RATE CHANGE
Employees wages were calculated: a. b. c. d. e. f. g. p Documents received _________________________ Weekly = $ __________________________________ gross weekly earnings at time of injury (attach wage documents). Monthly = $ __________________________________ x 12/52 = $ _____________________________________ gross weekly earnings (attach wage documents). Yearly = earnings $ _______________________________ ÷ 52 = $ ___________________________________ gross weekly earnings (attach wage documents). Day, hour, or output = most favorable 13 consecutive calendar weeks within the 52 calendar weeks immediately before the injury $ ____________________________________ ÷ 13 = $ ___________________________________ gross weekly earnings (attach wage documents). Worked less than 13 calendar weeks immediately before injury = $ ______________________ earnings ÷ 13 = $ _____________________ gross weekly earnings (attach wage documents). Wages not fixed at time of injury, explain how earnings determined ___________________________________________________________________________ Seasonal/Temporary : p Before 7/1/00 earnings for calendar year preceding date of injury $ ____________________÷ 50 =gross weekly earnings; p p p b. $ d. $ f. $ p b. SIF PAYMENT ONLY / / Alaska TTD Rate x p p c. From c. TERMINATION h. OTHER (Explain) d. Through e. Weeks & Days $ $ $ $ $ $ (If additional space is needed, use chart on reverse.) TOTAL f. Weekly Rate $ $ $ $ $ $ g. Total Amount p d. SUSPENSION Weekly TTD Rate Gross Earnings

Seasonal/Temporary : p After 7/1/00 earnings for 12 months immediately preceding date of injury $ _____________________÷ 50 =gross weekly earnings;

p p p p

h. i. j. k. a.

2 employers or more, use applicable methods above: Minor, apprentice, or trainee. Volunteer policeman, etc. Offset: Social Security (#39) or 155(i) (#40) Alaska TTD, PTD, death Alaska TPD Offset 41K e. Out-of-state TTD, PTD or death INITIAL PAYMENT l. Paid $110 minimum, explain _______________________________________________ 13. Date of injury before 9/4/952 year gross earnings = $__________________________ 14. Room, board or pension Weekly Rate* Tax & FICA x 80% = $ Maximum or Minimum $ Weekly Rate* Maximum or Minimum $ COLA Weekly Rate %=$ p e. RATE CHANGE p f. Date left Alaska

15. p

Gross Weekly Earnings

p p p

c.

($

Weekly Earning Capacity Tax & FICA x 80% = $ State Ratio

)=$

/

/

16. p p

a.

TYPE CHANGE

g. RESUMPTION Knowledge Date: b. Type

17. a. Payment Date

18. Impairment Rating: _______ % of $135,000 Whole Person (Prior to 7/1/2000) = $ __________________; After 7/1/2000, _________% of $177,000 Whole Person = __________________. 19. p Permanent impairment compensation was paid in a lump sum. (Enter amount in No. 17 and 18.) p If permanent impairment benefits not paid in a lump sum, enter date Employee requested reemployment benefits. 20. a. Date Disability Began Date _________________________________________ 21. Date Disability Ended

/

/
______________________ p At Same Job

b. First Payment Date

/

/
25. p

/

/

22.

TURN OVER AND COMPLETE ITEM 22 ON REVERSE

REASON FOR SUSPENSION, TERMINATION, RATE CHANGE, TYPE CHANGE, OR NONPAYMENT
23. p Returned to Work p At New Job

/

/

24. p

Released for Work

Date ________________________ p Regular Work

/

/

Medical Stability

26. p Compromise and Release 28. p Controversion (Attach 07-6105) 30. p Board Order

27. p C.O.L.A. 29. p Recomputation 31. p Other

Occupation _______________________________ Weekly Pay Rate $

p Modified Work

I certify that I have mailed the original of this report to the employee at the address above and a copy to the Alaska Workers Compensation Board.
32. Name and Title of Person Submitting Report (Type or Print) 33. Signature 34. Date

35. Address (if different from No. 11)

City

State

Zip

Telephone

Form 07-6104b (Rev.9/00)

EXPLANATIONS AND INSTRUCTIONS ON BACK

*From AWCB Tables

4

36. Employees Name (Last, First, Middle Initial)

37. Report Date

22. a. Employee Attorney Fees $ ______________________ d. Medical $ __________________________________ g. Reemployment $ ____________________________ i. Other (explain) 38. a. Payment Date

b. e.

Late Report Penalties $ __________________________ Second Injury Fund $ ___________________________ r SIF Check Attached

c. f. h.

Employer Attorney Fees $ ___________________________ Reemployment Plan Cost $ __________________________ Interest $ _______________________________________ $ ______________________________________________

______________________________________________________________________________________ b. Type c. From d. Through

e. Weeks & Days $ $ $ $ $

f. Weekly Rate $ $ $ $ $ $ $

g. Total Amount

FRONT PAGE TOTAL TOTAL 39. SOCIAL SECURITY OFFSET. (Applies only to some recipients of Social Security Benefits.) a. Social Security Retirement or Survivors Benefits (AS 23.30.225(a)). How the reduced weekly compensation was figured: (1) SS Monthly Benefit $ b. x 12/52 = SS Weekly Benefit $ x 1/2 = $ Reduction (2) Weekly Rate $ $ Reduction = $

Reduced Weekly Rate

Social Security Disability Benefits (AS 23.30.225(b)). How the reduced weekly compensation rate was figured: (1) SS Monthly Benefit $ x 12/52 = $ SS Wkly. Benefit $ (2) Gross Wkly. Earnings x 80% = $ Max. Wkly. Pmt. $ SS Wkly. Benefit = $ Reduced Wkly. Rate

40. Remarks

41. EXPLANATIONS AND ABBREVIATIONS a. Suspension, Item 16d. means the employer/insurer has stopped compensation payments expecting to pay more compensation later (usually the difference between the minimum and the documented rate). See paragraph 42a. below for effect on medical benefits. b. Termination, Item 16c. means the employer/insurer has stopped compensation payments with the belief all compensation due has been paid. See paragraph 40a. below, for effect on medical benefits. c. In Item 17b., the following abbreviations means the following types of disability: Dth = Death Benefits (Attach 07-6118) 25% = 25% Late Payment Penalty TTD = Temporary Total Disability TPD = Temporary Partial Disability PPI = Permanent Partial Impairment PTD = Permanent Total Disability 41K = Reemployment

d. Knowledge Date under Item 16g. means the date the employer/insurer learned about the employees resumed disability or PPI rating. e. SIF in Items 16b. and 22e. means Second Injury Fund. The insurer/employer makes this payment directly to the Alaska SIF, not the employee. SIF payments must be attached to the Boards annual report. The SIF payment does not affect the amount of compensation an employee receives.

42. TO EMPLOYEE (or other claimants in the case of death): READ CAREFULLY a. This report means the insurer/employer has begun, stopped or changed your compensation payments. The insurer/employer should continue to pay for medical treatment for your injury for at least two years after your injury date. Although the law lets the insurer/employer stop medical payments two years after your injury date, you may file a written claim asking the Alaska Workers Compensation (AWC) Board to authorize additional medical payments for treatment necessary to your recovery. b. YOU HAVE TWO YEARS FROM THE DATE OF THE COMPENSATION PAYMENT TO FILE A WRITTEN CLAIM FOR ADDITIONAL COMPENSATION PAYMENTS. c. If the AWC Board has issued a decision regarding your claim, you have one year from the date of the Boards order to file a written claim for a modification because of a change of condition or a mistake. If you have settled your claim by a compromise and release agreement which was approved by the AWC Board and later want to claim more benefits, contact the nearest AWC Board office for information. Attempts to get more benefits after an agreement seldom succeed. d. IF YOU BELIEVE THIS REPORT CONTAINS MISTAKEN INFORMATION, IF PAYMENTS HAVE STOPPED AND YOU CANNOT WORK BECAUSE OF YOUR INJURY, OR IF YOU HAVE QUESTIONS, CONTACT THE PERSON WHO SUBMITTED THE REPORT AT THE PHONE NUMBER OR ADDRESS GIVEN ON THE FRONT OF THIS REPORT. IF YOU AND THAT PERSON CANNOT AGREE, OR IF YOU STILL HAVE QUESTIONS, CONTACT THE NEAREST AWC BOARD OFFICE. SEND COPIES OF YOUR WAGE DOCUMENTS TO THE INSURER/EMPLOYER: DO NOT SEND THEM TO THE AWC BOARD.

ALASKA WORKERS COMPENSATION BOARD
ANCHORAGE 3301 Eagle Street P.O. Box 107019 Anchorage, Alaska 99510-7019 (907) 269-4980
Form 07-6104b (Rev. 9/00)

FAIRBANKS 675 7th Avenue Station H2 Fairbanks, Alaska 99701-4593 (907) 451-2889

JUNEAU 1111 West 8th Street P.O. Box 25512 Juneau, Alaska 99802-5512 (907) 465-2790