Form 07-6105 - Controversion Notice
Download a blank fillable Form 07-6105 - Controversion Notice in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 07-6105 - Controversion Notice with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2THIS NOTICE IS FROM THE INSURER/EMPLOYER. KEEP IT FOR YOUR RECORDS.
EMPLOYEE
:
READ IMPORTANT INFORMATION ABOUT YOUR RIGHTS ON BACK.
AWCB Case Number:
ALASKA DEPARTMENT OF LABOR &
CONTROVERSION NOTICE
WORKFORCE DEVELOPMENT
Alaska Workers' Compensation Board
P.O. Box 115512, Juneau AK 99811-5512
INSURER/EMPLOYER: This form is required if you desire to controvert (deny) payment of benefits. Complete and mail the
original to the employee with a copy to the Alaska Workers' Compensation Board.
1. Employee's Name (Last, First, Middle Initial)
2. Insurer Claim Number
3. Injury Date
4. Address
5. Date of Employer's First Knowledge
6. Social Security Number
City
State
Zip Code
Telephone
7. Birth Date
8. Employer
9. Insurer/Adjusting Company
10. Address
11. Insurer Address
Telephone
City
State
Zip Code
City
State
Zip Code
Telephone
12. Nature of Alleged Injury or Illness
Under the provisions of AS 23.30.155 the employer/insurer gives notice that the right to the benefit(s) described below is
controverted (denied) on the following grounds:
Reason for Controverting-State specific reasons and describe the evidence relied upon and not merely
conclusions. The controversion must have valid factual or legal objections to the payment of benefits.
Type of Benefits Controverted (Denied)
(Note: Failure to state specific reasons or lack of evidence to support denying benefits may result in this
notice being declared invalid and result in a penalty being awarded.)
14. Reason-All Benefits Controverted (Denied)
13.
All Benefits Controverted (Denied)
15. Specific Benefits Controverted (Denied)
16. Reason-Specific Benefits Controverted (Denied)
I certify that I have mailed the original of this notice to the employee at the address above and a copy to the Alaska Workers' Compensation Board.
17. Name and Title of Person Submitting Notice (Type or Print)
18. Signature
19. Date
20. Address (if different from No. 11)
City
State
Zip Code
Telephone
Form 07-6105 (Rev 07/2011)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal