Free Alaska Department of Labor - Alaska

Alaska Department of Labor and Workforce Development Fishermen's Fund PO Box 111149 Juneau, AK 99811-1149

Fishermen's Fund
FISHERMAN'S REPORT OF INJURY/ILLNESS & CLAIM FORM

Toll Free: 1-888-520-2766 Telephone: (907) 465-2766 Fax: (907) 465-5345 Email: [email protected] www.labor.state.ak.us/wc/fishfund.htm

You must file within one year of first treatment. Complete each item below ­ benefits cannot be paid if you do not provide the requested information. Attach a copy of your license/permit card with this form. 1. Name (Last, First, Middle Initial 5. Street or PO Box Number 8. City 10. Vessel Name State Zip Code 2. Sex M 3. Date of Birth F 7. Cell Phone Number ( ) 4. Social Security Number

6. Home Telephone Number ( ) 9. Email Address optional 12. Vessel Owner's Phone Number

11. Owner of Vessel/Set Net Site

13. Vessel Number

14. Commercial Fishing License or Permit Number Date Purchased Must Attach Copy 16. Geographic Location at time of injury (chart name or description, nearest landmark, etc) Be Specific 18. Resource Commercially Fished (ex. Salmon, Cod, Crab, etc)

15. Date and Time of Injury or Onset of Illness Date: Time:

am

pm

17. Ill/Injured while Commercial Fishing Working on gear/boat Other: 19. Gear Type (ex. Troll, Seine, Longline, Pot Gear, etc.)

20. Is the vessel/site insured by a protection & indemnity (P&I) insurance policy? Yes No Don't Know If yes, Insurance Company Name: Have you filed a claim against the vessel owner or the insurance company Yes No 21. At the time of your injury/illness, did you have medical coverage (including private health insurance, Indian health services, veterans affairs, Medicare, Medicaid, etc.)? Yes No If yes, name of coverage provider 22. What is the exact nature of your injury/illness? Be Specific

23. What caused the injury/illness? Be Specific

24. What were you doing at the time of injury? Be Specific

25. Was there a witness? witness address:

Yes

No If yes, witness name: telephone number:

To all health care providers: You are authorized to provide the Alaska Commercial Fishermen's Fund information concerning any health care advice, testing, treatment, or supplies provided to me for the injury or illness described above in box 21. This information will be used to evaluate my entitlement to receive medical benefits from the Fund. Claimant Signature Date

Warning: It is a crime to provide false information for the purpose of defrauding the Alaska Commerical Fishermen's Fund, or any other person. Penalties include fines and/or imprisonment. In addition, the Fund may deny all benefits if false information materially related to this claim was provided by the claimant. 07-6125 (Rev. 08/07)