Fill and Sign the Workers Compensation Alaska Dept of Labor Form

ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Alaska Workers' Compensation Board P.O. Box 115512, Juneau AK 99811-5512 COMPROMISE & RELEASE AGREEMENT SUMMARY INSTRUCTIONS: Complete and attach to the front of a compromise and release agreement s\ ubmitted to the Alaska Workers' Compensation Board. This form may not be used in place of or as a compromise and rele\ ase agreement. AWCB Case Number Only 2. Insurer Claim Number 3. Injury Date 1. Employee's Name (Last, First, Middle Initial) 4. Address City StateZip Code Telephone 5. Social Security Number 6. Date of Birth (Age) 7. Employee Attorney 8. Employer 9. Employer / Insurer Attorney 10. Insurer 11. Other Party or Attorney 12. Other Party or Attorney 13. Explain Relationship to Case 14. Explain Relationship to Case 15. How Did Accident Happen? 16. Describe Injuries: 17. Medical Reports: All medical reports in the parties' possession are \ attached. YES NO 18. Permanent Impairment Ratings a. ; ;       , Employee's Physician b. ; ;       , Employee's Physician % of % of % of By Dr. % of % of % of By Dr. 19. Occupation Before Injury 20. Average Weekly Wage 21. Occupation After Injury 22. Weekly Wage 23. Has Employee Returned to Work? YES, NO, Date: (Explain Why) 24. If Employee Returned to Work, Is He Working Now? YES NO, (Explain Why) 25. Was Employee Released for Work? NOT RELEASED REGULAR WORK MODIFIED WORK Date: Date: Limitations: 26. Is Vocational Rehabilitation Needed? NO YES UNKNOWN 27. Is Employee in a Vocational Rehabilitation Program? NO YES, (Describe) 28. Projected Vocational Rehabilitation Program Completion Date: 29. Summarize Dispute. a. Employee: b. Employer: Form 07-6117 (Rev 04/2010) CONTINUED ON BACK COMPROMISE & RELEASE AGREEMENT SUMMARY (Continued from Front) 30. Summarize Payments Made to Date or Attach a Compensation Report with\ a Total Payment History. a. Compensation (Complete a separate line for different rates, types or\ disability interruptions): TYPE FROM THROUGH WEEKS & DAYS WEEKLY RATE TOTAL AMOUNT LUMP SUM b. Medical: c. Other (Explain): Amount: TOTAL    COMPENSATION:  31. Agreed Settlement. a. Compensation (Complete a separate line for different rates, types or\ disability interruptions): TYPE FROM THROUGH WEEKS & DAYS WEEKLY RATE TOTAL AMOUNT LUMP SUM b. Medical Benefits Released? NO YES,Amount: TOTAL    COMPENSATION:  c. Attorney's Fees: Paid By: Employer Employe d. Vocational Rehabilitation Benefits Released? NO YES, Amount: e. REMARKS: f. Total Agreed Settlement Amount: 32. Submitted By (Name of Person and Company or Firm): 33. Date: FOR AWCB USE ONLY 34. COMMENTS: 35. DISPOSITION: APPROVE DISAPPROVE REQUEST INFORMATION RECOMMENDED HEARING 36. By: 37. Date: Form 07-6117 (Rev 04/2010)