ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT
REPORT OF OCCUPATIONAL INJURY
AWCB Case Number (Division Use Only):
Division of Workers' Compensation
P.O. Box 115512, Juneau AK 99811-5512
Answer ALL questions 1 - 20, sign, and give to your employer immediately.
1. Last Name
2. Telephone Number
3. Date of Birth
5. Social Security Number
6. Mailing Address
7. Residence Address
10. On Employer's Premises?
8. Place (City/Town/Village/Camp) Where Injury/Occupational Illness Happened
9. Date of Injury or Exposure to Disease
12. Hospitalization In-Patient?
11. Name & Address of Attending Physician
13. Name of Hospital
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.
17. If Employee Unavailable for Signature, Explain Circumstances in this Space
17a. Date Signed
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
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?
3 or More Days?
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
3 or Less
37. Federal EIN #
38. Give Details of How Injury or Illness Happened
35. Workday Began
36. Employee Paid for Day
Injured or Ill?
39. Injury / Illness Due to Machine /
40. Mechanical Guard / Safeguards
41. List Any Machine / Substance / Object Causing Injury
42. If Machine,What Part?
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
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.
Original -Workers' Compensation Division;
Form 07-6101 (Rev 04/2011)