Free Fisherman's Fund - Alaska


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State: Alaska
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http://www.labor.state.ak.us/wc/forms/crq519.pdf

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Compelling Reasons Questionnaire for Requests for Extension of Benefits or Time Alaska Commercial Fisherman's Fund

Compelling reasons are not defined in law but should be sufficient to justify the extension of benefits or time. The Fishermen's Fund Advisory and Appeals Council will use the financial status of the fisherman, impact of the injury/illness on the fisherman's ability to earn a living and any other compelling factors that affect the fisherman's ability to pay for related expenses in excess of $2500 in reviewing the request. Your responses to this questionnaire are strictly confidential and will only be reviewed by the Council in order to make determinations related to your application. Responses will not be released without a Release of Information signed by you, an attorney representing you, or your parents if under the age of 18. A written letter justifying an extension of benefits and/or time must be submitted in addition to this Questionnaire. Any further information can be submitted at any time. The relevant Alaska Statutes and the Fishermen's Fund brochure are attached for your reference. Please review pages 15 and 17 in the brochure. Estimates of anticipated medical or related expenses (i.e. air transportation) for future treatment, evaluation, or surgery, and the approximate date these will be completed should be provided in support of your request.

I request an extension of:

[ ] Time, 1 year extension Sections A, E [ ] Benefits - Sections B, C, D, E

A.

Extension of Time Has there been a gap of more than 3 months between any of your treatments in the last year? If yes, please note what other work, recreation, or other activities you have been involved in during that period; AND it is suggested you provide a medical doctor's statement that your commercial fishing activity, which "initiated" your injury/illness, remains the primary contributing factor to your condition. Please explain:

B.

Extension of benefits Impact on ability to earn a living while undergoing required treatment

1)

Did your physician prohibit your return to commercial fishing activities or restrict your work activities? Please explain:

2)

Were you required to undergo further treatment or therapy and how did your condition otherwise impact your ability to find commercial fishing work within the first 4 months after your injury/illness? Please explain:

3)

Does your condition prevent you from continuing to pursue a livelihood commercial fishing in Alaska? Please explain:

C.
1)

Extent of current and additional benefits requested Please provide a breakdown of your current and future costs. Provide further detail in an attachment and if available, letters from providers supporting estimate. CURRENT COSTS INCURRED Provider Total Cost
Fishermen's Paid by Me Fund Paid $________ $________ $________ $________ $________ $________

Balance

Hospital, emergency care, Radiology & anesthesiology $________ Doctor Therapy or Rehabilitation Air transportation to & from Treatment Other (taxis, lodging, meals are not covered) Subtotal
$________ $________

$________ $________ $________

$________

$________

$________

$________

$________

$________

$________

$________

$________

$________

$________

$________

ANTICIPATED/ESTIMATED COSTS TO BE INCURRED Hospital, emergency care, radiology and anesthesiology $_______ Please provide contact & telephone # to verify estimate: Name___________________ #______________ Physician/Doctor Please provide contact & telephone # to verify estimate: $_______

Name___________________

#_______________

Therapy or other related rehabilitation $_______ Please provide contact & telephone # to verify estimate: Name___________________ #_______________ Air transportation to & from treatment ( note if more than 1 trip) Other (taxis, lodging, meals are not covered): ___________________________________________________
TOTAL OF CURRENT AND ANTICIPATED COSTS

$________ $ ________

ESTIMATED INSURANCE, IF ANY. Please explain and note deductible. 2) What is the TOTAL of the additional benefits needed? 3) When does the doctor expect treatment, follow-up evaluations, etc. to end, whether provided by them or others (estimate month and year)?

($ _______ ) $ ________

____/ ____

D. Financial status
1) Please provide a breakdown of your total assets and liabilities. provided will be used to assess eligibility and extent of additional benefits. Balance Sheet (Fill in current balances for applicable items listed below) Assets: Cash $____________ Residence $____________ Vessel $____________ Gear $____________ Permits $____________ IFQ $____________ Stocks/Investments $____________ _____________ $____________ Total Assets $____________ Liabilities: Mortgage-Residence Mortgage-Vessel Fishing Loans Vehicle Credit Cards Other Loans _______________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ The details

Total Liabilities

$___________

Monthly Living Expenses (Fill in amounts for applicable items listed below) Mortgage/Rent Utilities Food Auto Insurance Health Insurance Life Insurance $__________ $__________ $__________ $__________ $__________ $__________

Auto Fuel Car Loan Payment Vessel Loan Payment Credit Card Payments Other Loan Payments Child Support Payments Clothing/Entertainment ________________ Total Monthly Living Expenses

$__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________

The extension of any relief (monetary benefits) or duration of care (time) granted by the Fishermen's Advisory and Appeals Council will be based on the total benefits and/or time requested in writing. Therefore, MAKE SURE YOUR TOTAL ADDITIONAL BENEFITS AND/OR AMOUNT OF TIME REQUESTED IS CLEARLY NOTED ABOVE and JUSTIFIED IN WRITING IN A SEPARATE LETTER! I authorize anyone possessing financial, credit, business or character information to release it to the Alaska Commercial Fishermen's Fund (all such information shall be kept confidential by that agency). Duplicates of this authorization shall have the same validity as the original.

E. Certification
I affirm all the above is true and certify under the penalty of perjury, __________________________ (Signature) __________________________ (Printed Name) __________________________ (Social Security Number) __________________________ (Date of Birth) Date___________________