Order Workers' Compensation Forms

Click the box in front of each form that you would like to order. Complete the address and organization information, click on the submit button, and we will send you the requested forms. You can select more than one form.

Form 6101: Report of Occupational Injury or Illness
Form 6102: Physician's Report
Form 6103: Medical Summary
Form 6104b: Compensation Report
Form 6105: Controversion Notice
Form 6106: Application for Adjustment of Claim
Form 6107: Affidavit of Readiness for Hearing
Form 6109: Petition to Join SIF and Claim for Reimbursement
Form 6110: Notice of Possible Claim Against the Second Injury Fund
Form 6111: Petition
Form 6112: Subpoena
Form 6117: Compromise and Release Agreement Summary
Form 6118: Death Benefits Report
Form 6120: Employers' Notice of Insurance
Form 6129: Application for Certificate of Self-Insurance
Form 6130: Renewing Status as A Self-Insured Employer in Alaska
Form 6135: Request for Conference
Form 6174: Request for Cross-Examination
Form 6175: Affidavit of Compensation Rate Less Than $154
Form xxxx: Waiver of Reemployment Benefits

Name:  Address:  Address 2: 
City:
 State:       Zip:   
        		Organization:
Phone:

        

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If you experience any problems using this form, simply email your request to: workcomp_forms@labor.state.ak.us.