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

Download a blank fillable Form 07-6111 - Petition - Alaska Department Of Labor & Workforce Development 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 Form 07-6111 - Petition - Alaska Department Of Labor & Workforce Development 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.

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):

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

22. Signature

23. Date

21. Name of Individual Filing this Form (Print or Type)

24. Address

City