Affidavit Of Compensation Rate Less Than 154

Download a blank fillable Affidavit Of Compensation Rate Less Than 154 in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Affidavit Of Compensation Rate Less Than 154 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

AWCB Case Number:
ALASKA DEPARTMENT OF LABOR &
AFFIDAVIT OF COMPENSATION
WORKFORCE DEVELOPMENT
RATE LESS THAN $154
Alaska Workers' Compensation Board
P.O. Box 115512, Juneau AK 99811-5512
2. Insurer Claim No.
3. Date of Injury
1. Employee's Name (Last, First, Middle Initial)
4. Employer
5. Insurer/Adjusting Company
6. HAVING FIRST BEEN DULY SWORN, I STATE
a. I am the adjuster assigned to handle this workers' compensation case.
b. To the best of my knowledge, the employee has provided documentation for all the wages the
employee earned in the two calendar years before injury.
c. According to the employee or the employee's former employers, the employee worked more
than six months in the two calendar years before injury.
d. Based on the wage documentation, under AS 23.30.220(a)(1) the employee's gross weekly
earnings are $
and the employee's weekly compensation rate is
$
.
8. Affiant's Signature
7. Name of Affiant (Print or Type)
SUBSCRIBED AND SWORN TO BEFORE ME THIS
DAY OF
,
.
9. Notary Public Signature
10. My Commission Expires
I certify that I have mailed the original of this affidavit to the employee and a copy to the Alaska Workers' Compensation
Board.
11. Name of Person Mailing Affidavit
13. Date Mailed
12. Signature
ATTACH TO COMPENSATION REPORT
Form 07-6175 (Rev 02/2010)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go