Form 07-6110 -Instructions For Completing Form 07-6110 Notice Of Possible Claim Against The Second Injury Fund - Alaska Wo Rkers Compensation Board
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1INSTRUCTIONS FOR COMPLETING FORM 07-6110
NOTICE OF POSSIBLE CLAIM AGAINST THE SECOND INJURY FUND
Filing form 07-6110 is prescribed by the Alaska Workers Compensation Board by regulation 8 AAC 45.186(a),
as amended by Bulletin 01-05, dated 12/15/2001. Any other type of notice will not be accepted.
A response must be provided in all areas – “N/A” is not an acceptable response. If the notice is incomplete, it
will be returned.
Items 1-8 – Provide the requested claim information.
Item 9 – List the qualifying pre-existing condition. Qualifying conditions include
(A) epilepsy
(N) hemophilia
(B) diabetes
(O) chronic osteomyelitis
(C) cardiac disease
(P) osteoporosis
(D) arthritis
(Q) ankylosis of joints
(E) amputated foot, leg, arm, or hand
(R) hyperinsulinism
(F) loss of sight of one or both eyes or a partial loss
(S) muscular dystrophies
of uncorrected vision of more than 75 percent
(T) arteriosclerosis
bilaterally
(U) thrombophlebitis
(G) residual disability from poliomyelitis
(V) varicose veins
(H) cerebral palsy
(W) heavy metal poisoning
(I) multiple sclerosis
(X) ionizing radiation injury
(J) Parkinson's disease
(Y) compressed air sequelae
(K) cerebral vascular accident
(Z) ruptured intervertebral disk
(L) tuberculosis
(AA) spondylolisthesis;
(M) silicosis
Item #10 – Examples of written records used to verify that the employer knowledge include
(A) Post Hire Health Questionnaire
(B) Personnel Records
(C) Medical Records
(D) Supervisor’s file notes
Item #11 – Examples of the possible combined effects include
(A) Combined effects may require additional medical treatment
(B) Combined effects may result in extended lost work time
(C) Combined effects may result in permanent disability
(D) Combined effects may result in a greater permanent partial impairment rating
Item #12 – Examples of dates used include
(A) Date opinion received from medical provider
(B) Date opinion received from medical case manager
(C) Date opinion received from claims adjuster
(D) Date opinion received from legal counsel, Board Decision and Order, or court ruling
Items 13-17 - Provide the name and daytime business telephone number of the person submitting the notice.
The notice must be signed and dated.
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