ALASKA DEPARTMENT OF LABOR &
AWCB Case Number:
Alaska Workers' Compensation Board
(Do Not Use As A Claim For Benefits)
P.O. Box 115512, Juneau AK 99811-5512
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
5. Social Security No.
6. Date of Birth
PETITION TYPE – CHECK APPROPRIATE BOXES.
RECONSIDERATION OR MODIFICATION
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
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
SIME - EXAMINATION BY BOARD-SELECTED PHYSICIAN
on all parties in accordance with 8 AAC 45.060.
UNDER AS 23.30.095(k)
REVIEW OF REEMPLOYMENT BENEFIT DECISION UNDER
REASON FOR PETITION – STATE IN DETAIL. ATTACH ADDITIONAL PAGES IF NECESSARY.
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):
The employee in #1 at the address in #4.
The employer in #7 at the address in #9.
The insurer in #8 at the address in #10.
Other (State Name and Address): _____________________________________
FORM WILL BE RETURNED UNLESS SIGNED BELOW
21. Name of Individual Filing this Form (Print or Type)
FILE WITH ALASKA WORKERS’ COMPENSATION BOARD
Form 07-6111 (Rev 07/2016)
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