Workers' Compensation Forms

Forms are available from the division. If you cannot get forms in time, write the details of your claim in a letter to the board, employer and insurer.

Workers' Compensation Forms in PDF Format

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.