Form 07-6104b - Compensation Report - 2011
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2This report is for your information. Keep it for your records.
EMPLOYEE:
Read important information about your rights on back.
ALASKA DEPARTMENT OF LABOR &
AWCB Case Number Only
COMPENSATION REPORT
WORKFORCE DEVELOPMENT
Alaska Workers' Compensation Board
P.O. Box 115512, Juneau AK 99811-5512
1. Employee's Name (Last, First, Middle Initial)
2. Insurer Claim Number
3. Injury Date
5a.
Single
4. Address
5b. Number of Dependents
6. Social Security Number
Married
(AWCB Use Only)
City
State
Zip Code
Telephone
7. Birth Date
8. Employer
9. Insurer/Adjusting Company
10. Address
11. Address
City
State
Zip Code
Telephone
City
State
Zip Code
Telephone
COMPENSATION RATE --COMPLETE FOR INITIAL PAYMENT OR RATE CHANGE
12.
Employee's wages were calculated:
$
a. Weekly =
(weekly earnings) gross weekly earnings at time of injury (attach wage documents).
$
$
b. Monthly =
(monthly earnings) x 12/52 =
gross weekly earnings (attach wage documents).
$
$
c. Yearly =
(yearly earnings) ÷ 52 =
gross weekly earnings (attach wage documents).
Day, hour, or output = earnings during either of the two calendar years immediately preceding the injury, whichever is most favorable to the employee
÷ 50 =
d.
$
$
gross weekly earnings (attach wage documents).
$
$
e. Worked less than 13 calendar weeks immediately before injury =
earnings ÷ 13 =
gross weekly earnings (attach wage documents).
f. Wages not fixed at time of injury, explain how earnings determined:
$
g. By the week or by the month, and employment is exclusively Seasonal/Temporary: = earnings for 12 calendar months immediately preceding date of injury
÷ 50 = gross weekly earnings;
h. 2 employers or more, use applicable methods above.
i. Minor, apprentice, or trainee.
k. Offset: Social Security (#39) or 155(i) (#40) (attach wage documents).
j. Volunteer policeman, etc.
l. Paid $110 minimum, explain
13.
a. Alaska TTD, PTD, Death
b. Gross Earnings
Gross Weekly Earnings
Weekly Rate*
Maximum or Minimum
- Tax & FICA x 80% =
c. Alaska TPD
d. Weekly TTD Rate
Weekly Earnings Capacity
Weekly Rate*
Maximum or Minimum
- Tax & FICA x 80% =
- (
) =
Offset 41K
e. Out-of-state TTD, PTD, Death f. Alaska TTD Rate
COLA Ratio
COLA Weekly Rate
Date Left Alaska
x
% =
14.
a. INITIAL PAYMENT
b. SIF PAYMENT ONLY
c. TERMINATION
d. SUSPENSION
e. RATE CHANGE
f. TYPE CHANGE
Knowledge Date:
h. OTHER (Explain)
g. RESUMPTION
15. a. Payment Date
b. Type
c. From
d. Through
e. Weeks & Days
f. Weekly Rate
g. Total Amount
(If additional space is needed, use chart on reverse.)
TOTAL
% of $177,000 Whole Person = $
16. Impairment Rating:
17.
Permanent impairment compensation was paid in a lump sum. (Enter amount in No. 15 and 16.)
If permanent impairment benefits not paid in a lump sum, enter date Employee requested reemployment benefits.
Date:
18. a. Date Disability Began
b. First Payment Date
19. Date Disability Ended
20. TURN OVER AND COMPLETE ITEM 20 ON REVERSE.
REASON FOR SUSPENSION, TERMINATION, RATE CHANGE, TYPE CHANGE, OR NONPAYMENT.
21.
22.
23.
24.
Date:
Returned to Work
Released for Work
Medical Stability
Compromise and Release
25.
26.
Date:
At New Job
At Same Job
C.O.L.A.
Controversion (Attach 07-6105)
27.
28.
Occupation
Regular Work
Recomputation
Board Order
Weekly Pay Rate $
29.
Modified Work
Other
I certify that I have mailed the original of this report to the employee at the address above and a copy to the Alaska Workers' Compensation Board
31. Signature
30. Name and Title of Person Submitting Report (Type or Print)
32. Date
33. Address (If Different From No. 11)
City
State
Zip Code
Telephone
Form 07-6104b (Rev 04/2011)
* From AWCB Tables
EXPLANATIONS AND INSTRUCTIONS ON BACK
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