Fillable Form 07-6105 - Controversion Notice (Page 2 of 2) in pdf

TO EMPLOYEE (OR OTHER CLAIMANTS IN CASE OF DEATH): READ CAREFULLY

This notice means the insurer/employer has denied payment of the benefits listed on the front of this form for the

reasons given. If you disagree with the denial, you must file a timely written claim (see time limits below). The

Alaska Workers' Compensation Board (AWCB) provides the "Workers' Compensation Claim" form for this

purpose. You must also request a timely hearing before the AWCB (see time limits below). The AWCB

provides the "Affidavit of Readiness for Hearing" form for this purpose. Get forms from the nearest AWCB

office listed below.

The insurer/employer must have valid legal grounds or evidence to support denying payment of the benefits listed on

the front of this form. If the insurer/employer did not have valid legal grounds or evidence to support the denial and

the benefits denied are due, you may be entitled to additional compensation (a penalty) of 25 percent of the benefits

due. To get this additional compensation, you must ask for a penalty when you complete and file your Workers'

Compensation Claim.

Also, if you believe the insurer did not have valid legal grounds or evidence to support the denial of benefits, when

you file your claim you may ask the AWCB to decide whether the insurer frivolously or unfairly controverted the

benefits. If the AWCB decides the denial was frivolous or unfair, the AWCB will notify the State of Alaska, Division of

Insurance. The Division of Insurance will decide if the insurer committed an unfair claim settlement practice.

TIME LIMITS

When must you file a written claim (Workers' Compensation Claim form)?

Compensation Payments.

You will lose your right to compensation payments unless you file a written claim within two years of

the date you know the nature of your disability and its connection with your employment and after

disablement. If the insurer/employer voluntarily paid compensation, you must file a written claim within

two years of the last payment.

Death Benefits.

You will lose your right to death benefits unless you file a written claim within one year of the

employee's death. There are, however, rare exceptions.

Medical Benefits.

There is no time limit for filing a claim for medical benefits. If the insurer/employer stops medical

payments, and if you believe you need more treatment, you must make a written claim to request

additional medical payments. The law permits the insurer/employer to stop medical payments two

years after your injury date, but the AWCB can authorize additional medical payments if treatment is

needed for the process of recovery.

When must you request a hearing (Affidavit of Readiness for Hearing form)?

If the insurer/employer filed this controversion notice after you filed a claim, you must request a hearing before

the AWCB within two years after the date of this controversion notice. You will lose your right to the benefits

denied on the front of this form if you do not request a hearing within two years.

IF YOU ARE UNSURE WHETHER IT IS TOO LATE TO FILE A CLAIM OR REQUEST A HEARING,

CONTACT THE NEAREST AWCB OFFICE.

ALASKA WORKERS' COMPENSATION BOARD

Anchorage

Fairbanks

Juneau

3301 Eagle Street, Suite 304

675 Seventh Avenue, Station K

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

Anchorage, AK 99503

Fairbanks, AK 99701-4586

1111 W 8th St Rm 305, Juneau AK 99801

Telephone: 907-269-4980

Phone: 907-451-2889

Telephone: 907-465-2790

Form 07-6105 (Rev 07/2011)

Form 07-6105 - Controversion Notice Page 2

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