Form 07-6101 - Report Of Occupational Injury Or Illness

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REPORT OF OCCUPATIONAL
Department of Labor and Workforce Development
Alaska Workers’ Compensation Board
INJURY OR ILLNESS
P.O. Box 25512, Juneau, Alaska 99802-5512
EMPLOYEE: Answer questions 1-20, immediately mail report. Further instructions on GREEN AND YELLOW page.
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EMPLOYER: Answer questions 18-49. Carefully follow instructions on PINK page.
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WARNING TO EMPLOYEES AND EMPLOYERS: Penalties for fraud or misleading statements. A person who
knowingly makes a false or misleading statement that adversely affects another person, is guilty of deception as
defined in AS 11.46.180, and may be punished as provided in AS 11.46.120-150.
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See Instructions on Back of Pink and Yellow Pages

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