Fill and Sign the Awcb Case Number Form

ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Alaska Workers' Compensation Board P.O. Box 115512, Juneau AK 99811-5512 REQUEST FOR CONFERENCE AWCB Case Number: Use this form to request a prehearing or settlement conference. It may be filed only after a “Workers' Compensation Claim” (Form 07-6106) or “Petition” (form 07-6111) has been filed. I. Attach a completed “Medical Summary” (form 07-6103) if you have new medical reports since you filed your last Medical Summary. II. If you want to raise additional issues not listed on your original Claim/Petition, an amended form MUST be attached. 1. Employee's Name (Last, First, Middle Initial) 2. Date of Injury 3. Address City State Zip Code Telephone 4. Social Security Number 5. Date of Birth 6. Employer 8. Employer Address City State Zip Code Telephone 7. Insurer/Adjusting Company 9. Insurer Address City Zip Code State Telephone 10. Please schedule a (CHOOSE ONE) Prehearing Conference or a Mediation in: Anchorage 3301 Eagle Street, Suite 304 Anchorage AK 99503 Fairbanks 675 7th Avenue, Station K Fairbanks, AK 99701-4593 Juneau P.O. Box 115512, Juneau AK 99811-5512 1111 W 8th Street, Suite 307, Juneau AK 99801 Reason for Prehearing: 11. Employee's claim was controverted: Yes No Date Controversion Notice filed: 12. Employee is now receiving compensation payments: Yes NoWeekly Rate $ 13. List the dates you will be available for a conference in the next 30 days: 14. Attorney's Name and Firm Name (if represented) 15. Attorney Address City State Zip Code Telephone 16. Name of Person Submitting Form (Print or Type) 17. Signature 18. AddressCity State Zip Code Telephone 19. PROOF OF SERVICE: I certify that on the date in #22 below, I mailed/delivered a true and correct copy of this request to the following (request will be returned with no action if all parties are not served): a. The employee in #1 above at the address in #3. b. The employer in #6 above at the address in #8. c. The insurer in #7 above at the address in #9. d. Other (State name and address): Name Address Name Address 20. Name of Person Serving Request 21. Signature 22. Date Form 07-6135 (Rev 11/2011)