ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Alaska Workers’ Compensation Division P.O. Box 115512 Juneau, AK 99811-5512 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 City State Zip Code Telephone 7. Occupation 8. Date of Birth 9. Employer at Time of Injury 10. Insurer/Adjusting Company 11. Address 12. Address City State Zip Code Telephone City State Zip Code Telephone 13. Describe how the injury or illness happened: 14. Part of Body Injured Right Left 15. Nature of injury or illness: 16. Full name and address of attending physician(s): 17. Reason for filing claim (be specific): 18. This claim amends a prior claim dated CONTINUED ON BACK 07-6106 (Revised 5/06) American LegalNet, Inc. www.FormsWorkflow.com WORKERS’ COMPENSATION CLAIM (Continued from Front) 19. Employee’s Name (Last, First, Middle Initial) 20. Date of Injury 22. Employer 23. Insurer/Adjusting Company 24. CLAIM IS MADE FOR a. Temporary Total Disability From Through 21. AWCB Case No. e. Medical Costs (state amount requested) i. Penalty (state amount requested) $ $ f. Transportation Costs (state amount requested) j. Interest From Through $ $ g. Review of Reemployment Benefit Decision k. Unfair or frivolous controvert (denial) From Through (1) Eligibility (2) Plan Review b. Temporary Partial Disability l. Attorney’s Fees and Costs (3) Employee Cooperation From Through $ (4) Other (Give details and amount requested c. Permanent Total Disability m. Death Benefits in #17 above) From Through d. Permanent Partial Impairment h. Compensation Rate (Gross Weekly Earnings) n. Other (Give details and amount Complete to #25 below requested in #17 above) 25. COMPLETE ONLY IF YOU CHECKED 24(h) ABOVE (Compensation Rate). ATTACH EARNING RECORDS AS INDICATED At the time of injury, Employee was a seasonal or temporary worker. (Attach copies of earnings documents for all work during the previous 12 months prior to the injury). b. Employee’s earnings were calculated by the day, hour, or output. (Attach copies of documents showing wages from all occupations during either of the two calendar years immediately preceding the injury, whichever is most favorable to the employee.) c. Employee’s earnings were calculated by the: Week Month Year (Attach copies of documents evidencing your rate of pay.) Employee’s wages had not been set or cannot be determined (Attach information about the usual wage for similar services). d. e. Employee was employed by two or more employers (Attach copies of earning records from all employers). Employee was a minor, apprentice, or trainee in a formal training program. f. g. Employee was injured working as a volunteer ambulance attendant, volunteer medical technician, or volunteer fire fighter. Employee was injured before November 7, 2005 h. 1. Employee was employed less than 13 weeks immediately before the injury. (Attach copies of documents showing what employee would have earned, including overtime and premium pay, if employed for 13 calendar weeks immediately before injury.) 2. Employee was employed 13 calendar weeks or more immediately before the injury. (Attach copies of earning records showing employee’s most favorable earnings for 13 consecutive calendar weeks within the 52 weeks immediately before injury.) i. Other a. 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) 29. Applicant’s Address 28. Telephone City State FORM WILL BE RETURNED UNLESS SIGNED BELOW 30. Attorney’s Name (if represented) Zip Code 31. Telephone 32. Attorney’s Address City 33. Name of individual Submitting the Form (print or type) 34. Signature 36. Address City State Zip Code 35. Date State Zip Code MAIL TO WORKERS’ COMPENSATION DIVISION 07-6106 (Revised 5/06) American LegalNet, Inc. www.FormsWorkflow.com