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Fill and Sign the Dolwd Division of Workers Compensation Information for

Fill and Sign the Dolwd Division of Workers Compensation Information for

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ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Alaska Workers' Compensation Board P.O. Box 115512, Juneau AK 99811-5512 AFFIDAVIT OF COMPENSATION RATE LESS THAN $154 AWCB Case Number: 1. Employee's Name (Last, First, Middle Initial) 2. Insurer Claim No. 3. Date of Injury 4. Employer 5. Insurer/Adjusting Company 6. HAVING FIRST BEEN DULY SWORN, I STATE a. I am the adjuster assigned to handle this workers' compensation case. b. To the best of my knowledge, the employee has provided documentation for\ all the wages the employee earned in the two calendar years before injury. c. According to the employee or the employee's former employers, the employ\ ee worked more than six months in the two calendar years before injury. d. Based on the wage documentation, under AS 23.30.220(a)(1) the employ\ ee's gross weekly earnings are $ and the employee's weekly com\ pensation rate is $ . 7. Name of Affiant (Print or Type) 8. Affiant's Signature SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF \ , . 9. Notary Public Signature 10. My Commission Expires I certify that I have mailed the original of this affidavit to the emplo\ yee and a copy to the Alaska Workers' Compensation Board. 11. Name of Person Mailing Affidavit 12. Signature 13. Date Mailed ATTACH TO COMPENSATION REPORT Form 07-6175 (Rev 02/2010)

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