Fill and Sign the 3301 Eagle Street Ste 304 Form

ALASKA WORKERS’ COMPENSATION BOARD 3301 Eagle Street, Ste 304 P.O. Box 107019 Anchorage, AK 99510-4970 (907) 269-4980 WAIVER OF REEMPLOYMENT BENEFITS AWCB Case No. INSTRUCTIONS: If you want to waive or give up reemployment benefits, carefully read this form, complete all the boxes, sign the form in front of a notary, and have it notarized. Then mail/deliver it to the Board at the address above. 1. Employee's Name (Last, First, Middle Initial) 3. Date of Injury: 4. Address: 5. Soc. Security No: City State Zip Code Telephone 6. Date of Birth: 7. Employer: 9. Insurer/Adjusting Company: 8. Employer Address: City State Zip Code Telephone 10. Insurer/Adjuster Address: City State Zip Code Telephone 11. Date Filed: 12. Date Served by the Board: (office use only) YOUR RIGHTS : * If you are injured at work, the law presumes you are entitled to workers’ compensation benefits, including reemployment benefits. * Your right to other workers’ compensation benefits (such as permanent partial impairment benefits) does not depend on giving up reemployment benefits. * You have the right to consult with an attorney before waiving or giving up reemployment benefits. * You have a right to discuss this waiver with a reemployment benefits staff member before signing it. You may contact a reemployment benefits staff member at 907-269-4980. * You have a right to ask for a prehearing conference to discuss this form with a Workers’ Compensation Officer and all parties before signing it. * You have the right to have this waiver of reemployment benefits form reviewed as a Compromise and Release (C&R) agreement by the Alaska Workers’ Compensation Board to determine if this waiver is in your best interest. * Before signing a waiver, you have the right to ask for an eligibility evaluation for reemployment benefits. The Reemployment Benefits Administrator of the Alaska Workers’ Compensation Division will decide whether or not you are entitled to reemployment benefits. I, _______________________ (s ignature ), have read and understand my rights, as explained above. 2 WHAT ARE REEMPLOYMENT BENEFITS ? If your job injury results in disabilities that prevent you from being able to return to your job at the time of injury, or jobs that that you held in the past, you may be able to receive job retraining under the workers’ compensation law. You may also be paid benefits while you are retraining. If you are an injured worker who is eligible for reemployment benefits, you are entitled to help from a trained professional (rehabilitation specialist) to find a new occupation that is appropriate. If you are eligible for reemployment benefits, a reemployment plan will be developed to teach you the new job skills needed. Your employer or insurance company is responsible for the costs of an approved or accepted reemployment plan. WAIVER OF RIGHTS TO WORKERS’ COMPENSATION REEMPLOYMENT BENEFITS (SIGN ONLY THOSE BENEFITS YOU INTEND TO GIVE UP): I, _______________________ (Signature), agree to waive or give up a possible eligibility evaluation (average payment of over $1,500.00 to rehabilitation specialist in 1998) under AS 23.30.041; I, _______________________ (Signature), agree to waive or give up rehabilitation plan costs (a maximum benefit of $13,300.00 for injuries after July 1, 2000 and $10,000.00 for injuries before July 1, 2000) under AS 23.30.041; I, _______________________ (Signature), agree to waive or give up possible compensation during the reemployment process at 70 percent of my spendable weekly wage under AS 23.30.041(k) (60 percent for injuries prior to July 1, 2000), for a period of up to two years after the approval or acceptance of a reemployment plan; I, _______________________ (Signature), agree to waive or give up the services of a rehabilitation specialist for reemployment plan development (average payment of over $3,400.00 to rehabilitation specialist in 1998); I, _______________________ (Signature), agree to waive or give up rehabilitation specialist’s services for watching over the reemployment plan (average payment of over $2,200.00 to rehabilitation specialist in 1998); I, _______________________ (Signature), agree to waive or give up all reemployment benefits under AS 23.30.041, including but not limited to those listed above. 3 ALL PERSONS WAIVING ANY REEMPLOYMENT BENEFITS MUST STATE THE FOLLOWING : I, _____________________________________(Signature), agree that, _________________________________ (name), the insurance adjuster handling my claim, or ________________________________, of the Alaska Workers' Compensation Division, explained what reemployment benefits are potentially available under AS 23.30.041, including but not limited to those listed above. I was told that I am completely giving up those benefits by signing this waiver form. In exchange for $_________________________________________________________________, as promised by the employer or insurer, __________________________, (name of employer or insurer), I,________________________________(signature) agree to waive or give up the reemployment benefits specified above. I, _______________________ (Signature), understand that my waiver of these specified benefits is permanent; this waiver may not be changed under AS 23.30.130 should my condition change or worsen at any time in the future. I, _______________________ (Signature), understand that this waiver of reemployment benefits forever releases the employer or insurer from paying for the benefits I am waiving or giving up in this document. I, _______________________ (Signature), have attached a report by Dr._______________ (name), showing I reached medical stability as of _______________(date). I, _______________________ (Signature), have attached a report by Dr.______________ (name), a physician, who predicted that I may have a permanent impairment from my work injury that may cause me to have permanent physical capacities that are less than the physical demands of my job at the time of injury. 4 AFFIDAVIT : I, ________________________, being first duly sworn or put under affirmation, depose and say: I am the employee in this waiver of reemployment benefits. In this document I waive or give up all my rights under AS 23.30.041 to those reemployment benefits I have specified and signed above. I understand what is stated in this form. To the best of my knowledge, the facts stated in this waiver of reemployment benefits are true and correct. I have signed this waiver of reemployment benefits voluntarily for the purposes of waiving or giving up the specified reemployment benefits. __________________________ Printed Name of Employee __________________________ Signature of Employee __________________________ Signature of Employee’s Representative SUBSCRIBED and SWORN to before me this ________ day of ______________, 20____. _____________________________ Notary Public in and for _______________ My Commission Expires: _______________ (AWCB approved 9/26/2000)