Alaska Department of Labor Alaska Workers’ Compensation Board P.O. Box 25512, Juneau, Alaska 99802-5512 AWCB Case Number WORKERS’ COMPENSATION CLAIM 1. Employee’s Name (Last, First, Middle Initial) 2. Insurer Claim Number 3. Injury Date 4. Address 5. City/Town/Village Where Injury Occurred 6. Social Security Number 7. Occupation 8. Date of Birth City State Zip Code Telephone 9. Employer at Time of Injury 10. Insurer/Adjusting Company 11. Address City 12. Address State Zip Code Telephone City State Zip Code Telephone 13. Describe how the injury or illness happened: ❒ Right 14. Part of body injured: ❒ Left 15. Nature of injury or illness: 16. Full name and address of attending physician(s): 17. Reason for Filing Application (be specific): From through From through 18. This Application Amends A Prior Application Dated _______________________________________________________ CONTINUED ON BACK Form 07-6106 (Rev. 8/97) 6 2001 © American LegalNet, Inc. WORKERS’ COMPENSATION CLAIM (Continued from Front) 19. Employee’s Name (Last, First, Middle Initial) 20. Date of Injury 21. AWCB Case No. 22. Employer 23. Insurer/Adjusting Company 24. CLAIM IS MADE FOR: a. r Temporary Total Disability From From Through From e. r Medical Costs (state amount requested) Through Through f. r Transportation Costs (state amount requested) c. d. (2) r Plan Review k. r Unfair or frivolous controvert (denial) l. (3) r Employee Cooperation Through r Attorney’s Fees and Costs $ (4) r Other (give details and amount requested Through r Permanent Partial Impairment r Interest (1) r Eligibility r Permanent Total Disability From j. $ r Temporary Partial Disability From r Penalty (state amount requested) $ g. Review of Reemployment Benefit Decision b. i. $ m. r Death Benefits in #17 above) h. r Compensation Rate (Gross Weekly Earnings) n. r Other (Give details and amount requested Complete to #25 below in #17 above) 25. COMPLETE ONLY IF YOU CHECKED 24h ABOVE (Compensation Rate). ATTACH EARNING RECORDS AS INDICATED At the time of injury, a. r Employee was a seasonal or temporary worker. (You should attach copies of earnings documents for all work for the calendar year immediately before injury.) b. r Employee was employed less than 13 calendar weeks immediately before the injury. (You should attach copies of documents showing what Employee would have earned, not including premium or overtime pay, if employed by Employer for 13 calendar weeks immediately before injury.) c. r Employee was employed 13 calendar weeks or more immediately before the injury: (Check 1 or 2 below) 1. r When injured, Employee’s earnings were calculated by the : r Week r Month r Year (You should attach copies of documents showing calculation of wages.) 2. r When injured, Employee’s earnings were calculated by the day, hour or output. (You should attach copies of earning records showing Employee’s most favorable earnings for 13 consecutive calendar weeks within the 52 weeks immediately before injury.) d. r Employee’s wages had not been set or cannot be determined. (You should attach information about the usual wage for similar services.) e. r Employee was employed by two or more employers. (You should attach copies of earning records from all employers.) f. r Employee was a minor, apprentice, or trainee in a formal training program. g. r Employee was injured working as a volunteer ambulance attendant, volunteer police officer, volunteer medical technician, or volunteer fire fighter. h. r Employee was injured before September 4, 1995. (You should attach copies of earnings documents for the two calendar years before injury and explain in #17 above if these do not fairly reflect Employee’s earnings during the period of disability.) i r Employee was injured on or after September 4, 1995, is permanently totally disabled, and wages calculated by Employer don’t fairly reflect earnings during the period of disability. j. r Other 26. TO BE USED IN DEATH CASES ONLY: It is claimed the deceased left the following beneficiaries: a. Name b. Age c. Relationship d. Address 27. Applicant’s Name (if other than employee) 28. Telephone 29. Applicant’s Address City State Zip Code FORM WILL BE RETURNED UNLESS SIGNED BELOW 30. Attorney’s Name (if represented) 32. Attorney’s Address 33. Name of Individual Submitting the Form (print or type) 36. Address 31. Telephone City 34. Signature City MAIL TO WORKERS’ COMPENSATION BOARD Form 07-6106 (Rev. 8/97) State Zip Code 35. Date State Zip Code 6 2001 © American LegalNet, Inc.