PETITION TO JOIN SECOND INJURY FUND AND CLAIM FOR REIMBURSEMENT ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Alaska Workers' Compensation Board P.O. Box 115512, Juneau AK 99811-5512 (For AWCB Use Only) (Type or Print) This form should be filed only after the employer or the insurer has submitted a Notice of Possible Claim Against the Second Injury Fund (AWCB form 07-6110) and has paid at least 104 weeks in compensation payments. Since regulation 8 AAC 45.186(f) does not allow the Second Injury Fund to make lump-sum reimbursements, reimbursement for compensation between 104 weeks and the filing date of this petition will be made on a monthly basis. Second Injury Fund reimbursements are for disability payments only; attorney fees, medical payments and 041 (k) wages will not be reimbursed. Payment will be at the claimant's weekly compensation rate. 1. Employee's Name (Last, First, Middle Initial) 2. Insurer Claim Number Date of Injury 3. Employee's Mailing Address 4. Employee's Social Security Number Date of Birth 5. Employer's Name 6. Insurer's Name 7. Employer's Mailing Address 8. Insurer's Mailing Address 9. Provide date that a Notice of Possible Claim was filed. (AWCB form 07-6110) 10. State how the pre-existing condition, which combined with the occupational injury, creates a compensable condition greater than the occupational injury alone. (Attach supporting medical summaries.) 11. Report all compensation payments made to date or attach a current compensation report containing a history of payments. Payment Date Payment Type From Through Weeks & Days Weekly Rate Total Amount Totals 12. Name of Individual Submitting This Form 13. Signature of Individiual Submitting Form 14. Date 15. Mailing Address 16. Telephone Number Form 07-6109 (Rev 04/2010) American LegalNet, Inc. www.FormsWorkFlow.com