Form 07-6110 - Notice Of Possible Claim Against The Second Injury Fund printable pdf download

Form 07-6110 - Notice Of Possible Claim Against The Second Injury Fund

NOTICE OF POSSIBLE CLAIM

AGAINST THE SECOND INJURY FUND

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 23.30.205(f). The notice must be filed within 100 weeks of the

date that the employer or the employer’s carrier has been informed that an injury meets the “combined effects”

test set out in AS 23.30.205(a). Copies of this form and attachments must be served on all interested parties

pursuant to 8 AAC 45.060.

Employee’s Name (Last, First, Middle Initial)

Insurer Claim Number

Date of Injury

Employee’s Mailing Address

Employee’s Social Security Number

Date of Birth

Employer’s Name

Insurer’s Name

7. Employer’s Mailing Address

8. Insurer’s Mailing Address

9. Provide description of applicable qualifying pre-existing condition, as set out in AS 23.30.205(d). (Attach supporting medical

evidence.)

10. Describe how the employer knew of the pre-existing condition prior to the subsequent occupational injury. (Attach evidence from

employer.)

11. Briefly describe how the pre-existing condition may combine with the occupational injury to create a compensable condition

greater than the occupational injury alone.

12. Provide date that the employer or insurer gained knowledge of the “combined effects” compensable condition described above.

(Attach supporting documentation.)

13. Name of Individual Submitting this Form

14. Signature of Individual Submitting Form

15. Date

16. Mailing Address

17. Telephone Number

Form 07-6110 (Rev 1/2/99)

Form 07-6110 - Notice Of Possible Claim Against The Second Injury Fund