Fill and Sign the Alaska Workers Compensation Alaska Department of Form

Form 07-6111 (Rev 09/2017) Page 1 of 1 ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Alaska Workers' Compensation Board P.O. Box 115512, Juneau AK 99811-5512 workerscomp@alaska.gov Petition (Do Not Use As A Claim For Benefits) AWCB Case Number: To the Person Receiving this Petition: You have 20 days after the date this petition was served on you to respond in writing or ask for a hearing before the Alaska Workers' Compensation Board (AWCB). Your res ponse to this petition must be filed with the AWCB, and it must show that a copy was given to the person who submitted this petition (see #21 below). If you have an attorney and you have questions, contact y our attorney. If you do not have an attorney and you have questions, contact the AWCB. 1. Employee’s Name (Last, First, Middle Initial) 2. Insure r Claim Number 3. Date of Birth 4. Date of Injury 5. Address City State Zip Code E-mail Address Telephone Fax Number 6. Employer 7. Insurer/Adjusting Company 8. Address City State Zip Code 9. Address City State Zip Code E-mail Address Telephone Fax Number E-mail address Telephone Fax Number PETITION TYPE – CHECK APPROPRIATE BOXES. 10. PROTECTIVE ORDER 11. COMPEL DISCOVERY 12. CONTINUE OR CANCEL HEARING 13. SIME - EXAMINATION BY BOARD-SELECTED PHYSICIAN UNDER AS 23.30.095(k) 14. REVIEW OF REEMPLOYMENT BENEFIT ADMINISTRATOR’S DECISION UNDER AS 23.30.041 15. RECONSIDERATION OR MODIFICATION 16. JOIN ADDITIONAL EMPLOYER(S) AND/OR INSURER(S): Pursuant to 8 AAC 45.040(g), the person or party to be joined as a party will be joined unless within 20 days after the service of this petition the person or party files an objection with the board and serves the objection on all parties in accordance with 8 AAC 45.060. 17. REQUEST FOR EXTENSION OF TIME TO REQUEST A HEARING UNDER AS 23.30.110(c) 18. OTHER: ___________________________________________ REASON FOR PETITION – STATE IN DETAIL. ATTACH ADDITIONAL PAGES IF NECESSARY. 19. COMPLETE MEDICAL SUMMARY (Form 07-6103) AND ATTACH IF REQUIRED UNDER 8 AAC 45.052. 20. PROOF OF SERVICE: I certify that on the date in #23 below I provided a true and correct copy of this petition on the following (your petition will be returned if you do not show serv ice to all parties and employers/insurers sought to be joined): a.The EMPLOYEE in #1 to the address/e-mail/fax in #5 by: Mail E-mail Facsimile b.The EMPLOYER in #6 to the address/e-mail/fax in #8 by: Mail E-mail Facsimile c.The INSURER in #7 to the address/e-mail/fax #9 by: Mail E-mail Facsimile d.OTHER (state name and address, e-mail or fax) by: Mail E-mail Facsimile FORM WILL BE RETURNED UNLESS SIGNED BELOW 21. Name of Individual Filing this Form (Print or Type)22. Signature 23. Date 24. Address City State Zip Code FILE WITH ALASKA WORKERS’ COMPENSATION BOARD