Form 07-6110 - Notice Of Possible Claim Against The Second Injury Fund

Download a blank fillable Form 07-6110 - Notice Of Possible Claim Against The Second Injury Fund in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 07-6110 - Notice Of Possible Claim Against The Second Injury Fund with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

NOTICE OF POSSIBLE CLAIM
AGAINST THE SECOND INJURY FUND
ALASKA DEPARTMENT OF LABOR &
(For AWCB Use Only)
WORKFORCE DEVELOPMENT
Alaska Workers' Compensation Board
P.O. Box 115512, Juneau AK 99811-5512
(Type or Print)
Filing this notice meets the requirements of AS 23.30.205(f). The notice must be filed within 100 weeks of the date
the employer or the employer's carrier obtained knowledge that the injury might possibly result in SIF compensable
harm to the injured worker. Copies of this form and attachments must be served on all interested parties pursuant to
8 AAC 45.060.
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 description of applicable qualifying pre-existing condition, as set out in AS 23.30.205(d).
10.Describe how the written records of the employer establish that the employer knew of the pre-existing condition prior to the subsequent occupational
injury. (A copy of the written record must either be attached to this notice or to the Petition for reimbursement when filed)
11.Briefly describe how the pre-existing condition may combine with the occupational injury to create a compensable condition greater than the occupational
injury alone. (Records documenting medical evidence of the combined effects must either be attached to this notice or to the Petition for reimbursement
when filed.)
12. Provide date that the employer or insurer gained knowledge of the “combined effects” compensable condition described above. (Records documenting
knowledge of the combined effects must either be attached to this notice or to the Petition for reimbursement when filed)
13. Name of Individual Submitting This Form
15. Date
14. Signature of Individual Submitting Form
16. Mailing Address
17. Telephone Number
Form 07-6110 (Rev 09/2012)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go