Form 07-6105 - Controversion Notice
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1THIS NOTICE IS FROM THE INSURER/EMPLOYER. KEEP IT FOR YOUR RECORDS.
EMPLOYEE:
READ IMPORTANT INFORMATION ABOUT YOUR RIGHTS ON BACK.
AWCB Case Number
ALASKA DEPARTMENT OF LABOR
Alaska Workers’ Compensation Board
CONTROVERSION NOTICE
P.O. Box 25512, Juneau, Alaska 99802-5512
INSURER/EMPLOYER: This form is required if you desire to controvert (deny) payment of benefits. Complete and mail the original to the
employee with a copy to the Alaska Workers’ Compensation Board.
1. Employee’s Name (Last, First, Middle Initial)
2. Insurer Claim Number
3. Injury Date
4. Address
5. Date of Employer’s First Knowledge
6. Social Security Number
City
State
Zip Code
Telephone
7. Birthdate
8. Employer
9. Insurer/Adjusting Company
10. Address
11. Address
City
State
Zip Code
Telephone
City
State
Zip Code
Telephone
12. Nature of Alleged Injury or Illness
Under the provisions of AS 23.30.155 the employer/insurer gives notice that the right to the benefit(s) described below is controverted
(denied) on the following grounds:
Reason for Controverting—State specific reasons and describe the evidence relied upon and not merely
conclusions. The controversion must have valid factual or legal objections to the payment of benefits. (Note:
Type of Benefits Controverted (Denied)
Failure to state specific reasons or lack of evidence to support denying benefits may result in this notice being
declared invalid and result in a penalty being awarded.)
14. Reason—All Benefits Controverted (Denied)
13.
All Benefits Controverted (Denied)
15. Specific Benefits Controverted (Denied)
16. Reason—Specific Benefits Controverted (Denied)
I certify that I have mailed the original of this notice to the employee at the address above and a copy to the Alaska Workers’ Compensation Board.
17. Name and Title of Person Submitting Notice (Type or Print)
18. Signature
19. Date
20. Address (if different from No. 11)
City
State
Zip
Telephone
Form 07-6105 (Rev. 8/97)
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