Form 07-6168 - Waiver Of Reemployment Benefits

WHAT ARE REEMPLOYMENT BENEFITS?

If your job injury results in disabilities that prevent you from being able to return to your job at the time of injury, or

jobs that that you held in the past, you may be able to receive job retraining under the workers' compensation law.

You may also be paid benefits while you are retraining.

If you are an injured worker who is eligible for reemployment benefits, you are entitled to help from a trained

professional (rehabilitation specialist) to find a new occupation that is appropriate. If you are eligible for

reemployment benefits, a reemployment plan will be developed to teach you the new job skills needed. Your

employer or insurance company is responsible for the costs of an approved or accepted reemployment plan.

WAIVER OF RIGHTS TO WORKERS' COMPENSATION REEMPLOYMENT BENEFITS

(SIGN ONLY THOSE BENEFITS YOU INTEND TO GIVE UP):

I, ______________________________ (Signature), agree to waive or give up a possible eligibility evaluation

(average payment of over $1,500.00 to rehabilitation specialist in 1998) under AS 23.30.041;

I, ______________________________ (Signature), agree to waive or give up rehabilitation plan costs (a

maximum benefit of $13,300.00 for injuries after July 1, 2000, and $10,000.00 for injuries before July 1, 2000)

under AS 23.30.041;

I, ______________________________ (Signature), agree to waive or give up possible compensation during the

reemployment process at 70 percent of my spendable weekly wage under AS 23.30.041(k) (60 percent for

injuries prior to July 1, 2000), for a period of up to two years after the approval or acceptance of a reemployment

plan;

I, ______________________________ (Signature), agree to waive or give up the services of a rehabilitation

specialist for reemployment plan development (average payment of over $3,400.00 to rehabilitation specialist in

1998);

I, ______________________________ (Signature), agree to waive or give up rehabilitation specialist's services

for watching over the reemployment plan (average payment of over $2,200.00 to rehabilitation specialist in 1998);

I, ______________________________ (Signature), agree to waive or give up all reemployment benefits under

AS 23.30.041, including but not limited to those listed above.

ALL PERSONS WAIVING ANY REEMPLOYMENT BENEFITS MUST STATE THE

FOLLOWING:

I, ______________________________ (Signature), agree that,

(Name), the insurance adjuster handling

my claim, or

, of the Alaska Workers' Compensation Division, explained what reemployment benefits are

potentially available under AS 23.30.041, including but not limited to those listed above. I was told that I am

completely giving up those benefits by signing this waiver form.

Form 07-6168 (Rev 12/2012)

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Form 07-6168 - Waiver Of Reemployment Benefits - 2012 Page 2