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Division of Workers' Compensation
State of Alaska > DOLWD > Workers' Compensation

List of Workers' Compensation Forms

Forms are in PDF Format

You may view and print any of the following documents with Adobe® Acrobat® Reader. This is free software that can be downloaded from the Adobe web site. For information about this process, click here.

Affidavit of Compensation Rate Less Than $154 (Form 07-6175)

Affidavit of Readiness for Hearing (Form 07-6107)

Claim for Benefits (Form 07-6106)

Compensation Report (Form 07-6104B)

Compromise and Release Agreement Summary (Form 07-6117)

Controversion Notice (Form 07-6105)

Death Benefits Report (Form 07-6118)

Employers' Notice of Insurance (Form 07-6120)

Executive Officer Waiver, Instructions & Form for Executive Officer Waiver (Form 07-6131)

Fishermen’s Fund, Carpal Tunnel Syndrome Questionnaire

Fishermen’s Fund, Claim Form (Form 07-6125)

Fishermen’s Fund, Compelling Reasons Questionnaire

Fishermen’s Fund, Medical and Related Transportation or Other Expenses

Fishermen’s Fund, Physician's Report (Form 07-6126)

Fishermen’s Fund, Report of Vessel/Site Insurance

Fishermen’s Fund, Vessel Owner (Employer) – Crewman Agreement

Medical Summary (Form 07-6103)

Petition (Form 07-6111)

Physician's Report (Form 07-6102)

Public Records Request (Form 07-6122)

Reemployment, Eligibility Evaluation Checklist (Form 07-6150)

Reemployment, Guide for Preparing Reemployment Benefits Eligibility Evaluations

Reemployment, Offer of Alternative Employment (Form 07-6151)

Reemployment, Waiver of Reemployment Benefits

Release of Counseling, Psychological, Psychiatric, or Alcohol/Drug/Substance Abuse Treatment Records or Information

Release of Medical Information

Report of Occupational Injury and Illness (Form 07-6101)

Request for Conference (Form 07-6135)

Request for Cross-examination (Form 07-6174)

Request for Release of Information (Form 07-6121)

Second Independent Medical Evaluation (SIME) (Form 07-6147)

Second Injury Fund, Notice of Possible Claim Against The Second Injury Fund
(Form 07-6110)

Second Injury Fund, Petition to Join Second Injury Fund and Claim for Reimbursement
(Form 07-6109)

Self-Insurance, Application for Certificate of Self-Insurance (Form 07-6129)

Self-Insurance, Parent Company Guarantee

Self-Insurance, Renewal of Certificate of Self-Insurance (Form 07-6130)

Subpoena (Form 07-6112)


 

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Contact Information:
Phone:
(907) 465-2790
Fax:
(907) 465-2797
   

Address:
P.O. Box 115512
Juneau, AK 99811-5512

 

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Page Updated February 4, 2010