Form 07-6101 - Report Of Occupational Injury Or Illness

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ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT

REPORT OF OCCUPATIONAL INJURY

AWCB Case Number (Division Use Only):

Division of Workers' Compensation

OR ILLNESS

P.O. Box 115512, Juneau AK 99811-5512

EMPLOYEE:

Answer ALL questions 1 - 20, sign, and give to your employer immediately.

4. Sex

1. Last Name

First Name

Initial

2. Telephone Number

3. Date of Birth

5. Social Security Number

6. Mailing Address

7. Residence Address

State

Zip Code

7a. City

State

Zip Code

6a. City

10. On Employer's Premises?

8. Place (City/Town/Village/Camp) Where Injury/Occupational Illness Happened

9. Date of Injury or Exposure to Disease

YES

12. Hospitalization In-Patient?

11. Name & Address of Attending Physician

13. Name of Hospital

YES

City

State

Zip Code

City

State

Zip Code

Left

Right

14. Describe Part(s) of Body Injured / Nature of Occupational Illness

15. Describe How the Injury or Occupational Illness Happened

16. To all health care providers:

You are authorized to provide my employer (named in box 18), its workers' compensation liability insurance company (box 21), and its claims adjuster (box 22) information

concerning any health care advice, testing, treatment, or supplies provided to me for the injury or illness described above in box 14. This information will be used to evaluate

my entitlement to receive benefits, including payment of medical benefits, under the Alaska Workers' Compensation Act. This authorization is valid for a one-year period from

the date of my signature (box 17a). I know I have a right to receive a copy of this authorization and agree a photographic copy of this authorization is as valid as the original.

Employee/Patient's Signature:

17. If Employee Unavailable for Signature, Explain Circumstances in this Space

17a. Date Signed

EMPLOYER:

Review employee answers 18 - 20, answer questions 21 - 49.

18. Employer's Name

19. Employer's Alaska Address (If Different from Mailing)

20. Employer's Mailing Address (Street and Number)

21. Name of Insurer

20a. City

State

Zip Code

20b. Telephone

22. Full Name and Address of Adjusting Company

23. Date Employer First Knew of Injury

24. Date/Time (AM / PM) Employee Left Work

22a. Mailing Address (Street and Number)

25. Off Work After Injury / Illness?

26. Date Returned to Work 27. Death?

22b. City

State

Zip Code

22c. Telephone

YES

3 or More Days?

Date

28. Location Where Injury or Occupational Illness Happened

29. Employee's Occupation

30. Date Hired By Employer

31. Earnings Calculated By

32. Rate of Pay

33. Days Employee Works per Week

34. Describe Scheduled Days Off

Hr.

Day

Output

Wk.

Mo.

Yr.

3 or Less

per

37. Federal EIN #

38. Give Details of How Injury or Illness Happened

35. Workday Began

36. Employee Paid for Day

Injured or Ill?

YES

39. Injury / Illness Due to Machine /

40. Mechanical Guard / Safeguards

41. List Any Machine / Substance / Object Causing Injury

42. If Machine,What Part?

Product Failure?

Provided?

YES

43. Name and Address of Witnesses

44. If Injury / Illness Caused by Anyone Besides Employee, Give Name and Address

45. Dependents (in case of death), Names and Addresses

46. If You Doubt Validity of Injury or Illness, State Reason

47. Signature of Authorized Employer or Representative

48. Title

49 Date Signed

WARNING TO EMPLOYEES AND EMPLOYERS: AS 23.30.250 imposes civil penalties for fraud as well as certain false or misleading statements and acts. Criminal penalties

for theft by deception (including fines and incarceration) apply to knowingly made false statements, claims, or employee misclassifications.

Distribution:

Original -Workers' Compensation Division;

Copy -Adjuster;

Copy -Employer;

Copy -Employee

Form 07-6101 (Rev 04/2011)