Free Notice of Possible Claim Against the Second Injury Fund - Alaska

NOTICE OF POSSIBLE CLAIM AGAINST THE SECOND INJURY FUND
ALASKA DEPARTMENT OF LABOR (For AWCB Use Only) Workers' Compensation Board P.O. Box 25512 Juneau, AK 99802-5512 (Type or Print) Filing this notice meets the requirements of AS 23.30.205(f). The notice must be filed within 100 weeks of the date the employer or the employer's carrier obtained knowledge that the injury might possibly result in SIF compensable harm to the injured worker. Copies of this form and attachments must be served on all interested parties pursuant to 8 AAC 45.060.
1. Employee's Name (Last, First, Middle Initial) 2. Insurer Claim Number Date of Injury Date of Birth

3. Employee's Mailing Address
5. Employer's Name

4. Employee's Social Security Number
6. Insurer's Name

7. Employer's Mailing Address

8. Insurer's Mailing Address

9. Provide description of applicable qualifying pre-existing condition, as set out in AS 23.30.205(d).

10. Describe how the written records of the employer establish that the employer knew of the pre-existing condition prior to the subsequent occupational injury. (A copy of the written record must either be attached to this notice or to the Petition for reimbursement when filed)

11. Briefly describe how the pre-existing condition may combine with the occupational injury to create a compensable condition greater than the occupational injury alone. (Records documenting medical evidence of the combined effects must either be attached to this notice or to the Petition for reimbursement when filed.)

12. Provide date that the employer or insurer gained knowledge of the "combined effects" compensable condition described above. (Records documenting knowledge of the combined effects must either be attached to this notice or to the Petition for reimbursement when filed) 13. Name of Individual Submitting this Form 16. Mailing Address 14. Signature of Individual Submitting Form 15. Date 17. Telephone Number

Form 07-6110 (Rev 09/10/2001)

INSTRUCTIONS FOR COMPLETING FORM 07-6110 NOTICE OF POSSIBLE CLAIM AGAINST THE SECOND INJURY FUND Filing form 07-6110 is prescribed by the Alaska Workers Compensation Board by regulation 8 AAC 45.186(a), as amended by Bulletin 01-05, dated 12/15/2001. Any other type of notice will not be accepted. A response must be provided in all areas ­ "N/A" is not an acceptable response. If the notice is incomplete, it will be returned. Items 1-8 ­ Provide the requested claim information. Item 9 ­ List the qualifying pre-existing condition. Qualifying conditions include (N) hemophilia (A) epilepsy (B) diabetes (O) chronic osteomyelitis (P) osteoporosis (C) cardiac disease (Q) ankylosis of joints (D) arthritis (R) hyperinsulinism (E) amputated foot, leg, arm, or hand (S) muscular dystrophies (F) loss of sight of one or both eyes or a partial loss (T) arteriosclerosis of uncorrected vision of more than 75 percent (U) thrombophlebitis bilaterally (V) varicose veins (G) residual disability from poliomyelitis (W) heavy metal poisoning (H) cerebral palsy (X) ionizing radiation injury (I) multiple sclerosis (Y) compressed air sequelae (J) Parkinson's disease (Z) ruptured intervertebral disk (K) cerebral vascular accident (AA) spondylolisthesis; (L) tuberculosis (M) silicosis Item #10 ­ Examples of written records used to verify that the employer knowledge include (A) Post Hire Health Questionnaire (B) Personnel Records (C) Medical Records (D) Supervisor's file notes Item #11 ­ Examples of the possible combined effects include (A) Combined effects may require additional medical treatment (B) Combined effects may result in extended lost work time (C) Combined effects may result in permanent disability (D) Combined effects may result in a greater permanent partial impairment rating Item #12 ­ Examples of dates used include (A) Date opinion received from medical provider (B) Date opinion received from medical case manager (C) Date opinion received from claims adjuster (D) Date opinion received from legal counsel, Board Decision and Order, or court ruling Items 13-17 - Provide the name and daytime business telephone number of the person submitting the notice. The notice must be signed and dated.