Form 07-6111 - Petition - Alaska Department Of Labor & Workforce Development

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ALASKA DEPARTMENT OF LABOR &
AWCB Case Number:
Petition
WORKFORCE DEVELOPMENT
Alaska Workers' Compensation Board
(Do Not Use As A Claim For Benefits)
P.O. Box 115512, Juneau AK 99811-5512
workerscomp@alaska.gov
To the Person Receiving this Petition: You have 20 days after the date this petition was served on you to respond in writing or ask for a hearing
before the Alaska Workers' Compensation Board (AWCB). Your response to this petition must be filed with the AWCB, and it must show that a copy
was given to the person who submitted this petition (see #21 below). If you have an attorney and you have questions, contact your attorney. If you do
not have an attorney and you have questions, contact the AWCB.
1. Employee’s Name (Last, First, Middle Initial)
2. Insurer Claim Number
3. Date of Injury
4. Address
5. Social Security No.
City
State
Zip Code
Telephone
6. Date of Birth
7. Employer
8. Insurer
9. Address
10. Address
City
State
Zip Code
Telephone
City
State
Zip Code
Telephone
PETITION TYPE – CHECK APPROPRIATE BOXES.
11.
PROTECTIVE ORDER
16.
RECONSIDERATION OR MODIFICATION
12.
COMPEL DISCOVERY
17.
JOIN ADDITIONAL EMPLOYER(S) AND/OR INSURER(S):
Pursuant to 8 AAC 45.040(g), the person or party to be joined as a party
13.
CONTINUE OR CANCEL HEARING
will be joined unless within 20 days after the service of this petition the
person or party files an objection with the board and serves the objection
14.
SIME - EXAMINATION BY BOARD-SELECTED PHYSICIAN
on all parties in accordance with 8 AAC 45.060.
UNDER AS 23.30.095(k)
18.
OTHER: ___________________________________________
15.
REVIEW OF REEMPLOYMENT BENEFIT DECISION UNDER
AS 23.30.041
REASON FOR PETITION – STATE IN DETAIL. ATTACH ADDITIONAL PAGES IF NECESSARY.
19.
COMPLETE MEDICAL SUMMARY (Form 07-6103) AND ATTACH IF REQUIRED UNDER 8 AAC 45.052.
20. PROOF OF SERVICE: I certify that on the date in #23 below I served a true and correct copy of this petition on the following (your petition will be
returned if you do not show service to all parties and employers/insurers sought to be joined):
a.
The employee in #1 at the address in #4.
b.
The employer in #7 at the address in #9.
c.
The insurer in #8 at the address in #10.
d.
Other (State Name and Address): _____________________________________
_____________________________________
_____________________________________
FORM WILL BE RETURNED UNLESS SIGNED BELOW
22. Signature
23. Date
21. Name of Individual Filing this Form (Print or Type)
24. Address
City
State
Zip Code
FILE WITH ALASKA WORKERS’ COMPENSATION BOARD
Form 07-6111 (Rev 07/2016)
Page 1 of 1

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