THIS NOTICE IS FROM THE INSURER/EMPLOYER. KEEP IT FOR YOUR RECORDS.
EMPLOYEE: READ IMPORTANT INFORMATION ABOUT YOUR RIGHTS ON BACK.
ALASKA DEPARTMENT OF LABOR Alaska Workers' Compensation Board P.O. Box 25512, Juneau, Alaska 99802-5512
AWCB Case Number
2. Insurer Claim Number 3. Injury Date
INSURER/EMPLOYER: This form is required if you desire to controvert (deny) payment of benefits. Complete and mail the original to the employee with a copy to the Alaska Workers' Compensation Board.
1. Employee's Name (Last, First, Middle Initial)
5. Date of Employer's First Knowledge
6. Social Security Number
9. Insurer/Adjusting Company
12. Nature of Alleged Injury or Illness
Under the provisions of AS 23.30.155 the employer/insurer gives notice that the right to the benefit(s) described below is controverted (denied) on the following grounds:
Type of Benefits Controverted (Denied) Reason for Controverting--State specific reasons and describe the evidence relied upon and not merely conclusions. The controversion must have valid factual or legal objections to the payment of benefits. (Note: Failure to state specific reasons or lack of evidence to support denying benefits may result in this notice being declared invalid and result in a penalty being awarded.) 14. Reason--All Benefits Controverted (Denied)
All Benefits Controverted (Denied)
15. Specific Benefits Controverted (Denied)
16. Reason--Specific Benefits Controverted (Denied)
I certify that I have mailed the original of this notice to the employee at the address above and a copy to the Alaska Workers' Compensation Board.
17. Name and Title of Person Submitting Notice (Type or Print) 18. Signature 19. Date
20. Address (if different from No. 11)
Form 07-6105 (Rev. 8/97)
TO EMPLOYEE (OR OTHER CLAIMANTS IN CASE OF DEATH): READ CAREFULLY
This notice means the insurer/employer has denied payment of the benefits listed on the front of this form for the reasons given. If you disagree with the denial, you must file a timely written claim (see time limits below). The Alaska Workers' Compensation Board (AWCB) provides the "Workers' Compensation Claim" form for this purpose. You must also request a timely hearing before the AWCB (see time limits below). The AWCB provides the "Affidavit of Readiness For Hearing" form for this purpose. Get forms from the nearest AWCB office listed below. The insurer/employer must have valid legal grounds or evidence to support denying payment of the benefits listed on the front of this form. If the insurer/employer did not have valid legal grounds or evidence to support the denial and the benefits denied are due, you may be entitled to additional compensation (a penalty) of 25 percent of the benefits due. To get this additional compensation, you must ask for a penalty when you complete and file your Workers' Compensation Claim. Also, if you believe the insurer did not have valid legal grounds or evidence to support the denial of benefits, when you file your claim you may ask the AWCB to decide whether the insurer frivolously or unfairly controverted the benefits. If the AWCB decides the denial was frivolous or unfair, the AWCB will notify the State of Alaska, Division of Insurance. The Division of Insurance will decide if the insurer committed an unfair claim settlement practice. TIME LIMITS 1. When must you file a written claim (Workers' Compensation Claim form)? a. Compensation Payments. You will lose your right to compensation payments unless you file a written claim within two years of the date you know the nature of your disability and its connection with your employment and after disablement. If the insurer/employer voluntarily paid compensation, you must file a written claim within two years of the last payment. b. Death Benefits. You will lose your right to death benefits unless you file a written claim within one year of the employee's death. There are, however, rare exceptions. c. Medical Benefits. There is no time limit for filing a claim for medical benefits. If the insurer/employer stops medical payments, and if you believe you need more treatment, you must make a written claim to request additional medical payments. The law permits the insurer/employer to stop medical payments two years after your injury date, but the AWCB can authorize additional medical payments if treatment is needed for the process of recovery.
2. When must you request a hearing (Affidavit of Readiness for Hearing form)? If the insurer/employer filed this controversion notice after you filed a claim, you must request a hearing before the AWCB within two years after the date of this controversion notice. You will lose your right to the benefits denied on the front of this form if you do not request a hearing within two years.
IF YOU ARE UNSURE WHETHER IT IS TOO LATE TO FILE A CLAIM OR REQUEST A HEARING, CONTACT THE NEAREST AWCB OFFICE.
ALASKA WORKERS' COMPENSATION BOARD Anchorage Location: 3301 Eagle, Suite 304 Mailing: P.O. Box 107019 Anchorage, AK 99510-7019 Phone: 269-4980 Fairbanks Location & Mailing: 675 Seventh Avenue Station H2 Fairbanks, AK 99701-4593 Phone: 451-2889 Juneau Location: 1111 W. 8th Street, Room 307 Mailing: P.O. Box 25512 Juneau, AK 99802-5512 Phone: 465-2790
Form 07-6105 (Rev. 8/97)