| 6101 |
Report Of Occupational Injury Or Illness. This
report is filed when injury occurs while employed. The employee’s portion of the form
must be filled out by the injured employee or by someone else if the employee is unable to
do so. Give the form to the employer to complete and distribute. |
| 6102 |
Physician’s Report. This form is filled out
by the physician each time the injured employee is treated. |
| 6103 |
Medical Summary. This form is used to list medical
reports to be relied upon at a hearing before the Board. This form usually accompanies an
Application for Adjustment of Claim (form 6106). |
| 6104b |
Compensation Report. This form gives details of
payments made to the employee and contains the formula used to calculate benefits. |
| 6105 |
Controversion Notice. This form is used by the
adjuster to deny some or all benefits. An injured employee disagreeing with a
controversion notice must file a written claim before requesting a Board hearing (forms
6106 and 6107). |
| 6106 |
Claim for Benefits. This form is used to file a
written claim when a dispute cannot be resolved between the employee and the adjuster.
Filing an application is the first step for an injured employee, the injured worker’s
attorney, or a medical provider to request a Board hearing. The adjuster has 20 days to
respond to the application after it is served by the Board. |
| 6107 |
Affidavit Of Readiness For Hearing. This form is
filed to request a hearing before the Board. An Application (form 6106) or Petition (form
6111) must be filed before an Affidavit of Readiness can be submitted. |
| 6109 |
Petition To join SIF And Claim For Reimbursement.
This form is used by the adjuster to request reimbursement from the Second Injury Fund for
compensation payments made to an injured worker. |
| 6110 |
Notice of Possible Claim Against the Second Injury
Fund. |
| 6111 |
Petition. This form is used to join additional
employers, terminate benefits or raise issues not appropriate to be claimed in an
application (form 6106). |
| 6112 |
Subpoena. This form is used to notify parties to
appear before the Board. |
| 6117 |
Compromise & Release Agreement Summary. This
form is used to summarize a settlement agreement reached by the parties to a workers’
compensation claim. |
| 6118 |
Death Benefits Report. This form is used by the
adjuster to itemize payments to the deceased’s dependents. |
| 6119 |
Insurance/Adjuster Notice |
| 6120 |
Employers’ Notice Of Insurance. This
completed form must be posted in three conspicuous places on your employer’s
premises. If this notice is not posted, it may mean your employer is not insured for
work-related injuries. |
| 6129 |
Application for Certificate of Self-Insurance. |
| 6130 |
Renewing Status as a Self-Insured Employer in Alaska. |
| 6135 |
Request for Conference. This form is used to
request a prehearing conference after filing an Application (form 6106) or Petition (form
6111). |
| 6174 |
Request For Cross-examination. This form is used
to request cross-examination of the author of any document relied upon by the parties. The
form is used by all parties to a dispute. |
| 6175 |
Affidavit Of Compensation Rate Less Than $154.
This form is used to justify paying a compensation rate less than the minimum after the
adjuster has received wage documentation from the employee. |
|
Waiver of Reemployment Benefits. Use this form if you want
to waive your reemployment benefits. |
