Fill and Sign the Box 115512 Juneau Ak 99811 5512 Form

07-6106 (Rev 12/2017) Page 1 of 1   ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Division of Workers’ Compensation P.O. Box 115512, Juneau, AK 99811-5512 Fax: (907) 465-2797 workerscomp@alaska.gov CLAIM FOR WORKERS’ COMPENSATION BENEFITS AWCB Case Number: This Claim form is used to request benefits an employer has not paid and to which you believe you are entitled. It should be filed only after the employer has reported the employee’s injury to the Division by filing a Report of Injury form. If the employer refuses to file or is unavailable to complete a Report of Injury form, please contact the Division. 1. Employee’s Name (Last, First, Middle Initial) 2. Insurer Claim Number 3. Injury Date 4. Address City State Zip Code 5. City/Town/Village Where Injury Occurred 6. Social Security No. 7. E-Mail Address (if available) Telephone 8. Occupation 9. Date of Birth 10. Name and Office of Employee’s Attorney (if no attorney, leave blank) 11. Employer at Time of Injury 12. Attorney’s Address (No., Street, City, State & Zip Code) 13. Employer Address (No., Street, City, State & Zip Code) 14. Attorney’s Telephone No. 15. Insurer/Adjusting Company 16. Attorney’s E-mail Address (Required) 17. Insurer/ Adjuster Address (No., Street, City, State & Zip Code) 18. Claim against the Benefits Guaranty Fund. Applies ONLY if the employer was NOT insured for workers’ compensation liability on the date of injury (the Division will verify employer’s coverage.) If the employer (box 11) was uninsured for workers’ compensation liability on the date of injury and failed to pay its employee (box 1) benefits due under the Alaska Workers’ Compensation Act, are you also filing against the Fund? YES NO 19. Describe the nature of the injury or illness, how the injury or illness happened, and part of body injured. Attach additional pages if necessary: _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ 20. Reason for filing claim (be specific): _______________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ 21. CLAIM IS MADE FOR: a. Temporary Total Disability f. Unfair or Frivolous Controversion (Denial) j. Penalty for Late Paid Compensation b. Temporary Partial Disability g. Attorney’s Fees and Costs k. Interest c. Permanent Total Disability h. Transportation Costs l. Death Benefits – Attach list of d. Permanent Partial Impairment i. Medical Costs (state amount beneficiaries, including name, age, relationship and address. requested) $ e. Compensation Rate Adjustment - Attach earnings records. m. Other (Give details and amount See brochure Workers’ Compensation & You for more information. requested in #20 above) 22. Claimant’s Name (if other than employee) 23. Telephone 24. Claimant’s Address City State Zip Code FORM WILL BE RETURNED UNLESS SIGNED BELOW 25. Name of Individual Submitting the Form (print or type) 26. Signature 27. Date 28. Address City State Zip Code 29. Telephone FILE WITH ALASKA WORKERS’ COMPENSATION BOARD