Form 07-6109 - Petition To Join Second Injury Fund And Claim For Reimbursement
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1PETITION TO JOIN SECOND INJURY FUND
AND CLAIM FOR REIMBURSEMENT
ALASKA DEPARTMENT OF LABOR &
(For AWCB Use Only)
WORKFORCE DEVELOPMENT
Alaska Workers' Compensation Board
P.O. Box 115512, Juneau AK 99811-5512
(Type or Print)
This form should be filed only after the employer or the insurer has submitted a Notice of Possible Claim Against the Second Injury Fund
(AWCB form 07-6110) and has paid at least 104 weeks in compensation payments. Since regulation 8 AAC 45.186(f) does not allow the
Second Injury Fund to make lump-sum reimbursements, reimbursement for compensation between 104 weeks and the filing date of this petition
will be made on a monthly basis. Second Injury Fund reimbursements are for disability payments only; attorney fees, medical payments and
041 (k) wages will not be reimbursed. Payment will be at the claimant's weekly compensation rate.
1. Employee's Name (Last, First, Middle Initial)
2. Insurer Claim Number
Date of Injury
3. Employee's Mailing Address
4. Employee's Social Security Number
Date of Birth
6. Insurer's Name
5. Employer's Name
7. Employer's Mailing Address
8. Insurer's Mailing Address
9. Provide date that a Notice of Possible Claim was filed. (AWCB form 07-6110)
10. State how the pre-existing condition, which combined with the occupational injury, creates a compensable condition greater than the
occupational injury alone. (Attach supporting medical summaries.)
11. Report all compensation payments made to date or attach a current compensation report containing a history of payments.
Payment Date
Payment Type
From
Through
Weeks & Days
Weekly Rate
Total Amount
Totals
12. Name of Individual Submitting This Form
14. Date
13. Signature of Individiual Submitting Form
15. Mailing Address
16. Telephone Number
Form 07-6109 (Rev 04/2010)
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