Instructions For Completing Form 07-6119 Insurance / Adjuster Notice

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INSTRUCTIONS FOR COMPLETING FORM 07-6119
INSURANCE / ADJUSTER NOTICE
Filing form 07-6119 is prescribed by the Alaska Workers Compensation Board. Any other type of proof of coverage, such as Accord
notices, will not be accepted. Do not file this form if coverage is federal (maritime or longshore & harbor workers).
A response must be provided in all marked (*) areas (1-7, 11-16, 20-23). If the notice is incomplete, it will be returned. Until a
corrected notice is resubmitted, the employer will be deemed in noncompliance and our regular proceedings against uninsured
employers will go forward. If the employer is self insured, do not use this form; contact the AWCB for an application for Certificate
of Self Insurance.
Items 1, 3 & 5 – Name and Address of Employer
List the legal name of the employer. If a sole proprietorship, list the first, last and middle initial of the individual owning the business.
If a partnership, list the names of each partner. If a corporation, list the complete name of the corporation. If a LLC, list the complete
name of the LLC. If subsidiary companies are included in a parent company’s policy, list the name of the parent company here and
the subsidiaries under item #10.
Items 2, 4 & 6 – Name and Address of Insurer
List the legal name of the insurance company (not group) who is providing coverage. The insurer must be a register property and
casualty provider as authorized by the State of Alaska, Division of Insurance.
Item #7 – EIN
List the federal employer’s identification number (FEIN). If the employer does not yet have a FEIN, list the employer’s social
security number.
Item #8 – Employer’s Alaska Unemployment Insurance Number
If available, provide the employer’s unemployment insurance payroll tax identification number.
Item #9 – Insurer’s NAIC Number
If available, provide the insurer’s National Association of Insurance Commissioner’s identification number.
Item #10 – Other Insured’s and/or DBA’s
Provide a complete list of the names and business location addresses for each company and/or assumed name under which the
employer listed in area #1 transacts business in Alaska. Attach a list to the notice if necessary.
Items 11 & 12 – Adjuster
List the name and address of the insurer’s claims adjuster. Alaska statutes require an insurer to provide, “claims facilities through its
own staffed adjusting facilities located within the state [underlined for emphasis], or by independent, licensed, resident [underlined for
emphasis] adjusters with power to effect settlement within the state”.
Items 13, 14, 15, & 16 – Policy Information
Provide the workers compensation policy number and coverage period for the policy. If the filing is for Cancellation or
Reinstatement, be sure to provide an effective date. Note that a cancellation is not effective until 20 days after written notice has
been filed with the Board, unless proof of coverage with another insurer has been submitted. If the notice is being filed due to an
employer name change, change of employer address, change of EIN, etc., be sure to place a check mark in the “other” box.
Item #17 – Remarks
Add any commentary to support the filing, i.e., the employer’s new name, new address, new EIN, change of policy period, change of
dba’s covered, etc. Attach a page to the notice form if more space is required.
Items 18 & 19 – Insurance Agent/Broker
If known, provide name and address of the employer’s insurance agent or broker.
Items 20, 21, 22, and 23 – Submitters Information
Provide the name and daytime business telephone number of the person submitted the notice. The notice must be signed and dated.

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