Form 07-6101 - Report Of Occupational Injury Or Illness (Page 4 of 5) in pdf

TO THE EMPLOYER

This form must be completed and mailed immediately and in no case later than ten (10) days after you have

knowledge that your employee has been injured or claims to have been injured while working for you.

Distribute copies of the form as follows:

Blue Copy ..................................................................

Alaska Workers’ Compensation Board

P.O. Box 25512

Juneau, AK 99802-5512

White Copy ................................................................

Your Adjuster or Insurance Company

(attach employee’s earnings information)

(not your Agent or Broker)

Pink Copy ..................................................................

Employer’s File

Yellow and Green Copies ...........................................

Employee

“Injury” means accidental injury or death arising out of and in the course of employment and an occupational

disease, illness or infection which arises naturally out of the employment or which naturally or unavoidably

results from an accidental injury.

“Injury” does not include mental injury caused by stress unless it is established that (A) the work stress was

extraordinary and unusual in comparison to pressures and tensions experienced by individuals in a

comparable work environment, and (B) the work stress was the predominant cause of the mental injury. A

mental injury is not considered to arise out of and in the course of employment if it results from a disciplinary

action, work evaluation, job transfer, layoff, demotion, termination or similar action, taken in good faith by the

employer.

Failure to file this report within the required time may subject you and/or your insurer to a penalty equal to

20% of the amount of compensation due plus interest to the injured worker.

If you believe the employee will be unable to work for more than three days because of injury, contact the

adjuster or insurer and provide information about employee’s earnings.

OSHA REQUIREMENTS

Report industrial deaths and accidents to the Division of Labor Standards and Safety. Alaska Statute

18.60.058 requires employers to report to the Division of Labor Standards and Safety an employment

accident which is fatal to one or more employees or which results in the in-patient hospitalization

hospitalization of one or more employees. The report, which must be made immediately, but no later

than 8 hours after receipt by the employer, of information that the accident has occurred, must relate the

circumstances of the accident, the number of fatalities and the extent of the injuries.

ALL INFORMATION IN THE WORKERS’ COMPENSATION BOARD

FILES, EXCEPT MEDICAL AND REHABILITATION RECORDS, IS

AVAILABLE FOR PUBLIC REVIEW AND COPYING.

Form 07-6101 - Report Of Occupational Injury Or Illness Page 4