Report Of Occupational Injury Or Illness
Report Of Occupational Injury Or Illness Form. This is a Alaska form and can be use in Workers Comp.
Tags: Report Of Occupational Injury Or Illness, 07-6101, Alaska Workers Comp,
ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Division of Workers' Compensation P.O. Box 115512, Juneau AK 99811-5512 EMPLOYEE: AWCB Case Number (Division Use Only): REPORT OF OCCUPATIONAL INJURY OR ILLNESS Answer ALL questions 1 - 20, sign, and give to your employer immediately. 1. Last Name First Name Initial 2. Telephone Number 3. Date of Birth 4. Sex 5. Social Security Number M 6. Mailing Address F 7. Residence Address State 6a. City 7a. City Zip Code State Zip Code 10. On Employer's Premises? YES NO 8. Place (City/Town/Village/Camp) Where Injury/Occupational Illness Happened 9. Date of Injury or Exposure to Disease 11. Name & Address of Attending Physician 12. Hospitalization In-Patient? 13. Name of Hospital YES NO City State Zip Code 14. Describe Part(s) of Body Injured / Nature of Occupational Illness City Left Right State Zip Code 15. Describe How the Injury or Occupational Illness Happened 16. To all health care providers: You are authorized to provide my employer (named in box 18), its workers' compensation liability insurance company (box 21), and its claims adjuster (box 22) information concerning any health care advice, testing, treatment, or supplies provided to me for the injury or illness described above in box 14. 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 17a). 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/Patient's Signature: 17. If Employee Unavailable for Signature, Explain Circumstances in this Space EMPLOYER: 17a. Date Signed Review employee answers 18 - 20, answer questions 21 - 49. 18. Employer's Name 19. Employer's Alaska Address (If Different from Mailing) 20. Employer's Mailing Address (Street and Number) 21. Name of Insurer 20a. City State 23. Date Employer First Knew of Injury Zip Code 20b. Telephone 24. Date/Time (AM / PM) Employee Left Work 25. Off Work After Injury / Illness? 26. Date Returned to Work 27. Death? YES Date NO 3 or More Days? 28. Location Where Injury or Occupational Illness Happened 31. Earnings Calculated By Output Day Hr. Wk. Mo. 32. Rate of Pay Yr. $ per 37. Federal EIN # 35. Workday Began 36. Employee Paid for Day NO PM Injured or Ill? YES AM Y 22. Full Name and Address of Adjusting Company 22a. Mailing Address (Street and Number) N 22b. City State 29. Employee's Occupation 33. Days Employee Works per Week 6 5 4 3 or Less 22c. Telephone 30. Date Hired By Employer 34. Describe Scheduled Days Off 7 38. Give Details of How Injury or Illness Happened 39. Injury / Illness Due to Machine / 40. Mechanical Guard / Safeguards 41. List Any Machine / Substance / Object Causing Injury Product Failure? YES NO Provided? YES NO 43. Name and Address of Witnesses Zip Code 42. If Machine,What Part? 44. If Injury / Illness Caused by Anyone Besides Employee, Give Name and Address 45. Dependents (in case of death), Names and Addresses 46. If You Doubt Validity of Injury or Illness, State Reason 47. Signature of Authorized Employer or Representative 48. Title 49 Date Signed 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. Distribution: Original -Workers' Compensation Division; Form 07-6101 (Rev 08/2012) Copy -Adjuster; Copy -Employer; Copy -Employee American LegalNet, Inc. www.FormsWorkFlow.com Instructions for REPORT OF OCCUPATIONAL INJURY OR ILLNESS TO THE EMPLOYEE You must complete and sign the “EMPLOYEE” section, questions 1-17, and answer questions 18-20 in the “EMPLOYER” section of this form. Keep a copy for your records. Immediately give this form to your employer. The employer will then complete their portion, and forward copies to their insurer, their claims administrator, and the Workers' Compensation Division. You should notify your employer immediately, but no later than 30 days after your injury occurred or illness began. After obtaining medical treatment, tell your health care provider's office to complete and mail the required “Physician's Report” (form 07-6102) to your employer's insurer for payment and to the Workers' Compensation Division for your file. A completed report is a requirement for payment under AS 23.30.095 (c). If you, your employer, and your doctor promptly file the required reports, there should be no delay in payment of compensation. You will not be paid compensation for lost wages for the first three 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 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 Workers' Compensation Division office nearest you (contact information listed below). If you are off work for 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 This form must be completed and mailed immediately, and in no case later than ten days after you have knowledge that your employee has been injured, or claims to have been injured or become ill while working for you. Be certain to mail a completed copy to the Workers' Compensation Division within the required 10-day period. Failure to file this report 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. AS 23.30.070 File the original of this form with the Alaska Division of Workers' Compensation, P.O. Box 115512, Juneau, AK 99811-5512. Keep a copy for your records, give a copy to the injured employee, and send a copy to your insurer's claims adjuster. If you believe the employee will be unable to work for more than three days because of injury or illness, be certain to complete items 31, 32, 33, and 34, or contact your insurer's claims adjuster and provide information about the injured employee's earnings. (Your insurer's claims adjuster is NOT the agent or broker from whom you purchased your workers' compensation liability insurance policy). Form 07-6101 (Rev 08/2012) American LegalNet, Inc. www.FormsWorkFlow.com OSHA REQUIREMENTS Report industrial deaths and accidents to the Division of Labor Standards and Safety. Alaska Statute 18.60.058 requires employers to report to Division of Labor Standards and Safety any employment accident which is fatal to one or more employees or which results in the overnight hospitalization of one or more employees. The report, which must be made immediately, but no later than 8 hours after receipt by the employer of information that the accident has occurred, must relate the circumstances of the accident, the number of fatalities, and the extent of the injuries. Monday-Friday Alaska OSH (800) 770-4940 · 24-hour OSHA Hotline (800) 321-6742 “Injury” means accidental injury or death arising out of in the course of employment and an occupational disease, illness, or infection which arises naturally out of the employment or which naturally or unavoidably results from an accidental injury. “Injury” does not include mental injury caused by stress unless it is established that (A) the work stress was extraordinary and unusual in comparison to pressures and tensions experienced by individuals in a comparable work environment, and (B) the work stress was the predominant cause of the mental injury. A mental injury is not considered to arise out of and in the course of employment if it results from a disciplinary action, work evaluation, job transfer, layoff, demotion, termination, or similar action taken in good faith by the employer. Alaska Worker's Compensation Division Offices: Anchorage: 3301 Eagle Street, #304 Anchorage, AK 99503-4149 (907) 269-4980 Alaska Labor Standards and Safety Division Offices: 3301 Eagle Street, #305 Anchorage, AK 99503-4149 (907) 269-4940 or (800) 770-4940 Fairbanks: 675 Seventh Avenue, Station K Fairbanks, AK 99701-4531 (907) 451-2889 Juneau: 1111 West 8th Street, #305 PO Box 115512 Juneau, AK 99811-5512 (907) 465-2790 Form 07-6101 (Rev 08/2012) 1111 West 8th Street, #304 PO Box 111149 Juneau, AK 99811-1149 (907) 465-4855 American LegalNet, Inc. www.FormsWorkFlow.com