ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Division of Workers' Compensation P.O. Box 115512, Juneau AK 99811-5512 EMPLOYEE REPORT OF OCCUPATIONAL INJURY OR ILLNESS TO EMPLOYER EMPLOYEE: All questions with an asterisk (*) must be completed 1. Employee Name Last* First* Middle Suffix 0043 0044 0045 0255 2. Mailing Address & Telephone Number* 3. Date of Birth* 4. Date of Death 0052 0057 0046 0047 5. Social Security Number* 6. Gender Code 0053 0270 & 0152/0153/0156/0042 City* State* Zip Code* F M 0048 0049 0050 7. Marital Status M-Married S-Separated Country, if outside the United States Telephone No. 0054 U-Unmarried K-Unknown 0155 0051 8. Number of Dependents 0055 9. Date of Injury / Illness* 10. Time of Injury / Illness 11. Did Injury / Illness Occur on Employer's Premises? 0031 0032 Y-Yes N-No 0249 12. Explain where injury / illness occurred 13. Employer Name* 0119 0018 14. Describe Nature of Injury / Illness* (i.e., sprain, laceration, etc.) 15. Describe Part of Body Affected* 0035 0036 16. Describe How the Injury / Illness Happened 0038 U 17. Injury / Illness Due to Machine/Product Failure? NA 18. Mechanical Guard/Safeguards Provided? NA 19. List Any Machine/Substance/Object Causing Injury / Illness 20. If Machine What Part? NA NA 21. Witness Name Witness Business Phone Number 0238 0237 0238 0237 22. Attending Physician Name & Contact Information 23. Hospital Name & Contact Information NA NA NA NA 24. Initial Treatment* 0039 0-No Medical Treatment 1-Minor On-site Remedies by Employer Medical Staff 2-Minor Clinic/Hospital Remedies and Diagnostic Testing 3-Emergency Evaluation, Diagnostic Testing, and Medical Procedures 4-Hospitalization Greater than 24 Hours 5-Future Major Medical/Lost Time Anticipated 25. Employee Authorization to Release Medical Records* 0150 To all health care providers: You are authorized to provide my employer (named in box 13), its workers' compensation liability insurance company, and its claims adjuster information concerning any health care advice, testing, treatment, or supplies provided to me for the injury or illness described above in box 16. This information will be used to evaluate my entitlement to receive benefits, including payment of medical benefits, under the Alaska Workers' Compensation Act. This authorization is valid for a one-year period from the date of my signature (box 23). I know I have a right to receive a copy of this authorization and agree a photographic copy of this authorization is as valid as the original. Employee Signature: 26. If Employee Unavailable for Signature, Explain Circumstances in this Space 27. Date Signed NA NA WARNING TO EMPLOYEES AND EMPLOYERS: AS 23.30.250 imposes civil penalties for fraud as well as certain false or misleading statements and acts. Criminal penalties for theft by deception (including fines and incarceration) apply to knowingly made false statements, claims, or employee misclassifications. ORIGINAL TO EMPLOYER IMMEDIATELY COPY TO EMPLOYEE EMPLOYER: File the complete First Report of Injury (FROI), form 07-6101, with the Alaska Division of Workers' Compensation by electronic data interchange (EDI), or by mail, within 10 days of receiving this report, per AS 23.30.070(a). 07-6100 (Rev. 04/01/2015) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Instructions for EMPLOYEE REPORT OF OCCUPATIONAL INJURY OR ILLNESS TO EMPLOYER TO THE EMPLOYEE You must complete and sign this form. Keep a copy of the completed form for your records, and immediately give this form to your employer. You should notify your employer immediately, but no later than 30 days after your injury occurred or illness began. The employer will notify their insurer, their claims administrator, and the Division of Workers' Compensation of your injury. After obtaining medical treatment, tell your health care provider's office to submit the required "Physician's Report" (8 AAC 45.086) to your employer. You will not be paid compensation for lost wages for the first three (3) days off work unless your disability lasts more than 28 days. The first installment of compensation becomes due on the 14th day after the employer has knowledge of the injury, illness or disease. After the first payment, you should get a check every two (2) weeks while you are disabled. If you have not received payment within 21 days from the date you were injured or became ill, contact the insurer or adjuster first. If you have any questions or problems, contact the Division of Workers' Compensation office nearest you (contact information listed below). If you are off work for three (3) or more days, you will need to provide additional information to your employer's claims adjuster regarding your wages, marital status, and number of dependents. If you believe your work-related injury or illness will keep you from returning to your job at the time of injury, you may need retraining. The training benefits to which you may be entitled, and how you go about getting them, depend on your date of injury. If you are off work for 45 days, contact the division office in Anchorage to learn more about your rights for reemployment benefits. You may also refer to the Reemployment Benefits section of the "Workers' Compensation and You" brochure available at the Division's internet web page: www.labor.state.ak.us/wc INFORMATION IN FILES MAINTAINED BY THE DIVISION OF WORKERS' COMPENSATION, EXCEPT FOR MEDICAL AND REHABILITATION RECORDS, IS AVAILABLE FOR PUBLIC REVIEW AND COPYING FOR NONCOMMERCIAL PURPOSES. AS 23.30.107 TO THE EMPLOYER The information on this form (07-6100) and the information on form 07-6101 must be submitted to the Division of Workers' Compensation immediately and in no case later than ten (10) days after you have knowledge that your employee has been injured, or claims to have been injured or become ill while working for you. Failure to file these reports within the required time may subject you and/or your insurer to a penalty equal to 20 percent of the amount of compensation due to the injured worker. Alaska Division of Worker's Compensation Offices Anchorage: 3301 Eagle Street, Suite 304 Anchorage, AK 99503-4149 (907) 269-4980 Fairbanks: 675 Seventh Avenue, Station K Fairbanks, AK 99701-4531 (907) 451-2889 Juneau: 1111 W 8th St, Rm 305, Juneau AK 99801 PO Box 115512, Juneau AK 99811-5512 (907) 465-2790 07-6100 (Rev. 04/01/2015) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com