ALASKA WORKERS' COMPENSATION BOARD P.O. Box 115512 JUNEAU, ALASKA 99811-5512 IN THE MATTER OF THE CLAIM FOR COMPENSATION AND/OR BENEFITS UNDER THE ALASKA WORKERS' COMPENSATION ACT Employee, vs. Employer, ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) and Adjuster. Date of Injury: AWCB Case No.: NOTICE OF INTENT TO RELY COMES NOW Employee and provides notice pursuant to 8 AAC 45.120(f) I intend to rely, and reserve the right to rely, on the following document(s) at hearing in the above-captioned case. Form 07-6114 (Rev 08/2010) American LegalNet, Inc. www.FormsWorkFlow.com Dated at , Alaska, this day of , . By: __________________________________ Signature Printed Name & Address: CERTIFICATE OF SERVICE The undersigned hereby certifies that on the day of , copies of the foregoing were mailed, first class postage prepaid, to the following: Claimant: Claimant Attorney: Adjusting Firm: Employer: Employer Attorney: Form 07-6114 (Rev 08/2010) American LegalNet, Inc. www.FormsWorkFlow.com