INSURANCE / ADJUSTER NOTICE
ALASKA DEPARTMENT OF LABOR
(For AWCB Use Only)
Workers Compensation Board
P.O. Box 25512
Juneau, AK 99802-5512
(Type or Print)
Filing this notice meets the requirements of AS 23.30.085(a). A response must be provided in all marked (*)
areas (1-7, 11-16, 20-23). If the notice is incomplete, it will be returned. Until a corrected notice is
resubmitted, the employer will be deemed in noncompliance and our regular proceedings against uninsured
employers will go forward. If the employer is self insured, do not use this form; contact the AWCB for an
application for Certificate of Self Insurance.
1.
Legal Name of Employer (Insured)*
2.
Insurer*
3.
Employer’s Mailing Address*
4.
Insurer’s Mailing Address*
5.
Telephone Number*
6.
Telephone Number*
7.
Employer’s FEIN No.*
Employer’s SSN (If no FEIN)
8. Employer’s AK UI No.
9. Insurer’s NAIC Number
10. Other names that the employer uses in Alaska (dba’s) and other legal entities in Alaska that are insured under this policy:
Name
Federal I.D. Number
AK UI Account Number
Business Address
(You may attach a list of dba’s with identification numbers and addresses to this form)
AS 23.30.030(4) requires that claims be handled by adjusting facilities located in Alaska. We will not accept an insurance notice that
contains an out-of-state address for the adjusting office.
11. Alaska Adjuster*
12. Alaska Adjuster’s mailing address*
Policy Information
13. Policy Number*
14. Policy Period*
From:
To:
15. Effective Date of Notice:*
¢
¢
¢
¢
16. Type of Filing (Check One)*
New Policy
Policy Renewal
Reinstatement
Cancellation
¢
¢
Change of adjuster (attach a list of corresponding claims)
Other (explain in space provided)
Cancellation is not effective until 20 days after written notice has been filed with the Board.
17. Remarks (Name or Ownership Change, Business Sold, etc. Be Specific.)
18. Name of Agent/Broker
19. Mailing Address of Agent/Broker
20. Name of Person Submitting Notice*
21. Signature*
22. Date*
23. Telephone Number*
Form 07-6119 (Rev 8/2/99)