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Controversion Notice Form. This is a Alaska form and can be use in Workers Comp.
Tags: Controversion Notice, 07-6105, Alaska Workers Comp,
THIS NOTICE IS FROM THE INSURER/EMPLOYER. KEEP IT FOR YOUR RECORDS. EMPLOYEE: READ IMPORTANT INFORMATION ABOUT YOUR RIGHTS ON BACK ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Alaska Workers' Compensation Board P.O. Box 115512 Juneau, Alaska 99811-5512 AWCB Case Number: CONTROVERSION NOTICE INSURER/EMPLOYER: This form is required if you desire to controvert (deny) payment of benefits. Complete and mail the original to the employee with a copy to the Alaska Workers' Compensation Board. 1. Employee's Name (Last, First, Middle Initial) 2. Insurer Claim No. 3. Injury Date 4. Address 5. Date of Employer's First Knowledge 6. Social Security Number City State Zip Code Telephone 7. Birth Date 8. Employer 9. Insurer/Adjusting Company 10. Address 11. Address City State Zip Code Telephone City State Zip Code Telephone 12. Nature of Alleged Injury or Illness Under the provisions of AS 23.30.155 the employer/insurer gives notice that the right to the benefit(s) described below is controverted (denied) on the following grounds: Reason for Controverting-State specific reasons and describe the evidence relied upon and not merely conclusions. The controversion must have valid factual or legal objections to the payment of benefits. (Note: Failure to state specific reasons or lack of evidence to support denying benefits may result in this notice being declared invalid and result in a penalty being awarded.) 14. Reason-All Benefits Controverted (Denied) 13. All Benefits Controverted (Denied) Type of Benefits Controverted (Denied) 15. Specific Benefits Controverted (Denied) 16. Reason-Specific Benefits Controverted (Denied) I certify that I have mailed the original of this notice to the employee at the address above and a copy to the Alaska Workers' Compensation Board. 17. Name & Title of Person Submitting Notice (Type or Print) 18. Signature 19. Date 20. Address (if different from No. 11) City State Zip Code Telephone Form 07·6105 (Rev. 11/2014) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com TO EMPLOYEE (OR OTHER CLAIMANTS IN CASE OF DEATH): READ CAREFULLY This notice means the insurer/employer has denied payment of the benefits listed on the front of this form for the reasons given. If you disagree with the denial, you must file a timely written claim (see time limits below). The Alaska Workers' Compensation Board (AWCB) provides the "Workers' Compensation Claim" form for this purpose. You must also request a timely hearing before the AWCB (see time limits below). The AWCB provides the "Affidavit of Readiness for Hearing" form for this purpose. Get forms from the nearest AWCB office listed below. The insurer/employer must have valid legal grounds or evidence to support denying payment of the benefits listed on the front of this form. If the insurer/employer did not have valid legal grounds or evidence to support the denial and the benefits denied are due, you may be entitled to additional compensation (a penalty) of 25 percent of the benefits due. To get this additional compensation, you must ask for a penalty when you complete and file your Workers' Compensation Claim. Also, if you believe the insurer did not have valid legal grounds or evidence to support the denial of benefits, when you file your claim you may ask the AWCB to decide whether the insurer frivolously or unfairly controverted the benefits. If the AWCB decides the denial was frivolous or unfair, the AWCB will notify the State of Alaska, Division of Insurance. The Division of Insurance will decide if the insurer committed an unfair claim settlement practice. TIME LIMITS 1. When must you file a written claim (Workers' Compensation Claim form)? a. Compensation Payments. You will lose your right to compensation payments unless you file a written claim within two years of the date you know the nature of your disability and its connection with your employment and after disablement. If the insurer/employer voluntarily paid compensation, you must file a written claim within two years of the last payment. b. Death Benefits. You will lose your right to death benefits unless you file a written claim within one year of the employee's death. There are, however, rare exceptions. c. Medical Benefits. There is no time limit for filing a claim for medical benefits. If the insurer/employer stops medical payments, and if you believe you need more treatment, you must make a written claim to request additional medical payments. The law permits the insurer/employer to stop medical payments two years after your injury date, but the AWCB can authorize additional medical payments if treatment is needed for the process of recovery. 2. When must you request a hearing (Affidavit of Readiness for Hearing form)? If the insurer/employer filed this controversion notice after you filed a claim, you must request a hearing before the AWCB within two years after the date of this controversion notice. You will lose your right to the benefits denied on the front of this form if you do not request a hearing within two years. IF YOU ARE UNSURE WHETHER IT IS TOO LATE TO FILE A CLAIM OR REQUEST A HEARING, CONTACT THE NEAREST AWCB OFFICE. ALASKA WORKERS' COMPENSATION BOARD Anchorage 3301 Eagle Street Suite 304 Anchorage, AK 99503 Telephone: 907-269-4980 Fairbanks 675 Seventh Avenue, Station K Fairbanks, AK 99701-4531 Telephone: 907-451-2889 Juneau P.O. Box 115512, Juneau AK 99811-5512 1111 W 8th St Rm 305, Juneau AK 99801 Telephone: 907-465-2790 Form 07·6105 (Rev. 11/2014) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com