Form 07-6168 - Waiver Of Reemployment Benefits - 2012
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4ALASKA WORKERS' COMPENSATION BOARD
Division of Workers’ Compensation, Reemployment Benefits Section
3301 Eagle Street, Suite 301, Anchorage, Alaska 99503-4149
Telephone: (907) 269-4985
WAIVER OF REEMPLOYMENT BENEFITS
AWCB Case No
INSTRUCTIONS: If you want to waive or give up reemployment benefits, carefully read this form, complete all the
boxes, sign the form in front of a notary, and have it notarized. Then mail/deliver it to the Board at the address
above.
1. Employee's Name (Last, First, Middle Initial):
2. Date of Injury:
3. Address:
4. Social Security No.:
City
State
Zip Code
Telephone
5. Date of Birth:
6. Employer:
7. Insurer/Adjusting Company:
8. Employer Address:
9. Insurer/Adjuster Address:
City
State
Zip Code
Telephone
City
State
Zip Code
Telephone
11. Date Filed:
12. Date Served by the Board:
(office use only)
YOUR RIGHTS:
If you are injured at work, the law presumes you are entitled to workers' compensation benefits, including
reemployment benefits.
Your right to other workers' compensation benefits (such as permanent partial impairment benefits) does
not depend on giving up reemployment benefits.
You have the right to consult with an attorney before waiving or giving up reemployment benefits.
You have a right to discuss this waiver with a reemployment benefits staff member before signing it. You
may contact a reemployment benefits staff member at 907-269-4980.
You have a right to ask for a prehearing conference to discuss this form with a Workers' Compensation
Officer and all parties before signing it.
You have the right to have this waiver of reemployment benefits form reviewed as a Compromise and
Release (C&R) agreement by the Alaska Workers' Compensation Board to determine if this waiver is in
your best interest.
Before signing a waiver, you have the right to ask for an eligibility evaluation for reemployment benefits.
The Reemployment Benefits Administrator of the Alaska Workers' Compensation Division will decide
whether or not you are entitled to reemployment benefits.
I, ______________________________ (Signature), have read and understand my rights, as explained above.
Form 07-6168 (Rev 12/2012)
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