Form 07-6101 - Report Of Occupational Injury Or Illness Page 2
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3Instructions for REPORT OF OCCUPATIONAL INJURY OR ILLNESS
TO THE EMPLOYEE
You must complete and sign the “EMPLOYEE” section, questions 1-17, and answer questions 18-20 in
the “EMPLOYER” section of this form. Keep a copy for your records. Immediately give this form to your
employer. The employer will then complete their portion, and forward copies to their insurer, their claims
administrator, and the Workers' Compensation Division. You should notify your employer immediately, but
no later than 30 days after your injury occurred or illness began.
After obtaining medical treatment, tell your health care provider's office to complete and mail the
required “Physician's Report” (form 07-6102) to your employer's insurer for payment and to the
Workers' Compensation Division for your file. A completed report is a requirement for payment under
AS 23.30.095 (c).
If you, your employer, and your doctor promptly file the required reports, there should be no delay in
payment of compensation. You will not be paid compensation for lost wages for the first three days off
work unless your disability lasts more than 28 days. The first installment of compensation becomes due on
the 14th day after the employer has knowledge of the injury, illness or disease. After the first payment, you
should get a check every two weeks while you are disabled. If you have not received payment within 21
days from the date you were injured or became ill, contact the insurer or adjuster first. If you have any
questions or problems, contact the Workers' Compensation Division office nearest you (contact
information listed below). If you are off work for 3 or more days, you will need to provide additional
information to your employer's claims adjuster regarding your wages, marital status, and number of
dependents.
If you believe your work related injury or illness will keep you from returning to your job at the time of injury,
you may need retraining. The training benefits to which you may be entitled, and how you go about getting
them, depend on your date of injury. If you are off work for 45 days, contact the division office in
Anchorage to learn more about your rights for reemployment benefits. You may also refer to the
Reemployment Benefits section of the “Workers' Compensation and You” brochure available at the
Division's internet web page:
INFORMATION IN FILES MAINTAINED BY THE DIVISION OF WORKERS'
COMPENSATION, EXCEPT FOR MEDICAL AND REHABILITATION RECORDS IS
AVAILABLE FOR PUBLIC REVIEW AND COPYING FOR NONCOMMERCIAL PURPOSES.
AS 23.30.107
TO THE EMPLOYER
This form must be completed and mailed immediately, and in no case later than ten days after you have
knowledge that your employee has been injured, or claims to have been injured or become ill while
working for you. Be certain to mail a completed copy to the Workers' Compensation Division within the
required 10-day period. Failure to file this report within the required time may subject you and/or your
insurer to a penalty equal to 20 percent of the amount of compensation due to the injured worker.
AS 23.30.070
File the original of this form with the Alaska Division of Workers' Compensation, P.O. Box 115512, Juneau,
AK 99811-5512. Keep a copy for your records, give a copy to the injured employee, and send a copy to
your insurer's claims adjuster. If you believe the employee will be unable to work for more than three days
because of injury or illness, be certain to complete items 31, 32, 33, and 34, or contact your insurer's
claims adjuster and provide information about the injured employee's earnings. (Your insurer's claims
adjuster is NOT the agent or broker from whom you purchased your workers' compensation liability
insurance policy).
Form 07-6101 (Rev 04/2011)
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