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Notice of Possible Claim Against the Second Injury Fund

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NOTICE OF POSSIBLE CLAIM
AGAINST THE SECOND INJURY FUND

ALASKA DEPARTMENT OF LABOR
Workers' Compensation Board
P.O. Box 25512
Juneau, AK 99802-5512

(For AWCB Use Only)

(Type or Print)

Filing this notice meets the requirements of AS 23.30.205(f). The notice must be filed within 100 weeks of the date the employer or the employer's carrier obtained knowledge that the injury might possibly result in SIF compensable harm to the injured worker. Copies of this form and attachments must be served on all interested parties pursuant to 8 AAC 45.060.

1. Employee's Name (Last, First, Middle Initial)

2. Insurer Claim Number

Date of Injury

3. Employee's Mailing Address

4. Employee's Social Security Number

Date of Birth

5. Employer's Name

6. Insurer's Name

7. Employer's Mailing Address

8. Insurer's Mailing Address

9. Provide description of applicable qualifying pre-existing condition, as set out in AS 23.30.205(d).

10. Describe how the written records of the employer establish that the employer knew of the pre-existing condition prior to the subsequent occupational injury. (A copy of the written record must either be attached to this notice or to the Petition for reimbursement when filed)

11. Briefly describe how the pre-existing condition may combine with the occupational injury to create a compensable condition greater than the occupational injury alone. (Records documenting medical evidence of the combined effects must either be attached to this notice or to the Petition for reimbursement when filed.)

12. Provide date that the employer or insurer gained knowledge of the “combined effects” compensable condition described above. (Records documenting knowledge of the combined effects must either be attached to this notice or to the Petition for reimbursement when filed)

13. Name of Individual Submitting this Form

14. Signature of Individual Submitting Form

15. Date

16. Mailing Address

17. Telephone Number

Form 07-6110 (Rev 09/10/2001)

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What the Notice of Possible Claim Against the Second Injury Fund Is

The Notice of Possible Claim Against the Second Injury Fund is a formal written notification used in workers' compensation systems to alert the Second Injury Fund or equivalent state entity that a claimant has a work-related injury combined with a pre-existing impairment. The notice documents the claimant's identity, employer, date of injury, nature of prior impairment, and medical evidence linking the current injury to an increased loss of earning capacity. It does not itself adjudicate liability but preserves a party's right to seek fund participation or reimbursement under applicable state workers' compensation statutes.

Why this Notice Matters for Claim Resolution

Filing the notice preserves the right to seek additional compensation when a new workplace injury worsens an existing impairment, clarifies potential fund liability, and creates a documented record for adjudication.

Why this Notice Matters for Claim Resolution

Who Typically Prepares and Receives This Notice

The notice is prepared and submitted in multi-party workflows involving claimants, employers, insurers, and counsel. It must reach the state fund administrator or designated claims office.

  • Claimants and family representatives — to preserve rights and document combined impairments for possible fund recovery.
  • Employers and workers' compensation carriers — to report potential fund exposure and initiate internal claims handling.
  • Workers' compensation attorneys and claims administrators — to compile evidence and manage formal submission and appeals.

Core Parts of a Professional Notice of Possible Claim

A complete notice collects claimant details, injury and employment facts, prior impairment documentation, a medical nexus statement, calculation of increased impairment, and required signatures and service information.

Claimant Details

Full legal name, date of birth, address, employer, claim or file number, and contact information for correspondence and verification.

Injury Description

Date and location of the workplace injury, description of incident, body parts affected, and treating providers identified with dates of treatment.

Pre-existing Impairment

Medical diagnosis, date of onset, prior impairment rating or functional limits, and documentation establishing the earlier condition.

Medical Nexus

Physician statement or records explaining how the new injury combined with pre-existing impairment to increase disability or impair earning capacity.

Damages Calculation

Summary of how increased impairment was measured, permanent impairment ratings, and any statutory method used to compute fund contribution.

Signatures & Service

Signature blocks for claimant or representative, employer/carrier acknowledgement if required, dates, and proof of delivery or service details.

Step-by-Step: Complete and Submit the Notice

Follow these steps in sequence to prepare a clear, complete notice and confirm delivery to the fund administrator and interested parties.

  • 01
    1. Gather Records: Collect prior medical records, employer reports, and current treating physician statements.
  • 02
    2. Complete Form: Enter claimant, employer, injury, and prior impairment fields accurately.
  • 03
    3. Attach Evidence: Upload supporting medical reports, impairment ratings, and employer documentation.
  • 04
    4. File and Serve: Submit to the fund office and serve copies on employer and insurer with proof of delivery.

Where the Notice Goes and What Happens Next

Filing routes and subsequent administrative steps vary by state; below are typical destinations and expected actions after submission.

  • Fund Administrator: Primary recipient for eligibility review and contribution determination.
  • Employer / Carrier: Receives notice for internal recordkeeping and response on liability or reimbursement.
  • Claimant Representative: Retention of a copy enables appeals and follow-up medical evidence.
  • Adjudication Panel: May request additional records, schedule hearings, or reach settlement determinations.

Configuring an Online Submission Workflow

Set up an electronic workflow that captures required fields, enforces attachments, and records signer authentication for auditability.

Field Configuration
Authentication Email link with optional SMS code or stronger ID verification where required
Required Attachments Make medical reports and impairment ratings mandatory upload fields
Conditional Fields Show prior impairment fields only when claimant indicates pre-existing condition
Notifications Auto-notify fund, employer, and claimant upon submission and completion

Technical and Platform Considerations for eSubmission

Use platforms that support PDF/Word uploads, robust audit trails, and secure signer authentication to meet legal and administrative requirements.

  • File Formats: PDF, DOCX, and exportable audit logs
  • Integrations: Salesforce, NetSuite, Microsoft 365, Google Workspace
  • Security: TLS in transit and AES-256 at rest

Typical eSignature Vendor Comparison for Filing and Serving Notices

Comparing core pricing and capabilities can help organizations choose an eSignature platform that supports secure submission, bulk routing, and compliance with health and privacy requirements.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial, no credit card Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes (premium tier) Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Security and Compliance Considerations for Electronic Notices

Encryption: AES-256 at rest; TLS 1.2/1.3 in transit
Access Controls: Role-based permissions and administrative logging
Audit Trail: Timestamped signer events and IP address records
BAA Availability: Business Associate Agreement available where HIPAA applies
Authentication: Email, SMS code, or advanced ID verification
Exportability: Downloadable signed PDF and certificate of completion

Consequences of Incomplete or Incorrect Notices

Missed Deadline: May forfeit fund recovery
Incomplete Evidence: Claim denied or delayed
Unsigned Document: Considered invalid by administrator
Wrong Recipient: Processing delays and resubmission
Data Privacy Breach: Regulatory and reputational risk
Fraud Allegations: Potential civil or criminal exposure

Common Preparation Mistakes to Avoid

  • Omitting prior impairment documentation leads to incomplete claims and denials.
  • Using inconsistent names or claim numbers prevents file matching by administrators.
  • Failing to sign or date the notice invalidates submission in many jurisdictions.
  • Submitting unsupported medical reports without provider identification reduces evidentiary weight.

Practical Tips for Accurate and Efficient Notices

Adopt consistent templates, require mandatory attachments, and keep auditable submission records to reduce processing time and increase acceptance rates.

Use a Standard Template
Maintain a version-controlled template that includes all mandatory fields and checklists to reduce omissions and reviewer questions.
Verify Identity and Claim Numbers
Confirm claimant legal name, birth date, and insurer claim number before filing; mismatches commonly cause delays.
Attach Signed Medical Evidence
Include provider-signed reports with dates and license details to substantiate nexus and prior impairment history.
Record Service and Delivery
Preserve proof of delivery or electronic completion certificates to support timeliness and procedural compliance.

Real-World Examples of Electronic Notice Workflows

Organizations across industries have moved notice submission and supporting evidence online to reduce in-person steps and retain reliable audit records.

Optica Ventures LLC

A mid-size firm centralized claim notices into an online workflow to eliminate paper transfer delays.

  • They reduced time-to-service by removing manual routing.
  • The interface is simple and easy-to-use for our team; more importantly, it is just as easy for our customers.

Martin Properties

A field-heavy operator used mobile signing to collect incident and impairment notices on site.

  • Signatures were captured at point-of-contact and routed automatically.
  • I can process and execute all of these documents online with 100% compliance and built-in security. Whether on mobile or working offline, I can get forms back to their necessary parties efficiently.

Key Milestones from Notice to Funding Determination

Typical milestone stages start at initial filing and continue through review, requests for additional evidence, and final funding decisions or appeals.

01

Initial Notice Filed

Submit notice and service proof to the fund administrator for intake.

02

Administrative Review

Fund reviews records and requests clarifying information as needed.

03

Medical Evaluation

Independent review or examination may be scheduled to assess combined impairment.

04

Funding Determination

Authority issues eligibility and contribution decision, subject to appeal.

Time-Sensitive Items to Track When Filing

Monitor statutory filing windows, employer notice requirements, and any administrative deadlines to preserve rights and avoid denial.

Statute of Limitations:

Varies by state; commonly 1–3 years from date of injury or discovery.

Employer Reporting Period:

Employers may have internal reporting windows that affect fund notice timing.

Support Submission Window:

Some funds require evidence within a set period after initial notice.

RON Recording Retention:

If remote notarization used, audio-video recordings typically retained 5–10 years.

Appeal Deadline:

Administrative appeal windows are time-limited—confirm jurisdictional rules.

Frequently Asked Questions About Filing the Notice

Answers to common questions about timing, signatures, evidence, and electronic filing to help prevent delays and jurisdictional errors.


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