Claim For Workers' Compensation Benefits
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1ALASKA DEPARTMENT OF LABOR &
AWCB Case Number:
WORKFORCE DEVELOPMENT
CLAIM FOR
Division of Workers’ Compensation
WORKERS’ COMPENSATION BENEFITS
P.O. Box 115512, Juneau, AK 99811-5512
Fax: (907) 465-2797
workerscomp@alaska.gov
This Claim form is used to request benefits an employer has not paid and to which you believe you are entitled. It should be filed only after the employer has reported the employee’s injury
to the Division by filing a Report of Injury form. If the employer refuses to file or is unavailable to complete a Report of Injury form, please contact the Division.
1. Employee’s Name (Last, First, Middle Initial)
2. Insurer Claim Number
3. Injury Date
4. Address (No., Street, City, State & Zip Code)
5. City/Town/Village Where Injury Occurred
6. Social Security No.
7. E-Mail Address (if available)
Telephone
8. Occupation
9. Date of Birth
10. Name and Office of Employee’s Attorney (if no attorney, leave blank)
11. Attorney’s Telephone No.
12. Attorney’s Address (No., Street, City, State & Zip Code)
13. Attorney’s E-mail Address (Required)
14. Employer at Time of Injury
15. Insurer/Adjusting Company
16. Address (No., Street, City, State & Zip Code)
17. Address (No., Street, City, State & Zip Code)
18. Claim against the Benefits Guaranty Fund (Fund). If you suspect the employer (box 14) was uninsured for workers’ compensation liability on the
date of injury and failed to pay its employee (box 1) benefits due under the Alaska Workers’ Compensation Act, you may be able to file a claim against
the Fund. The Division will verify and confirm employer’s workers’ compensation coverage. Are you also filing against the Fund?
YES
NO
19. Describe the nature of the injury or illness, how the injury or illness happened, and part of body injured. Attach additional pages if necessary:
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
20. Reason for filing claim (be specific.) Attach additional pages if necessary: _________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
21. CLAIM IS MADE FOR:
a.
Temporary Total Disability
f.
Unfair or Frivolous Controversion (Denial)
j.
Penalty for Late Paid Compensation
b.
Temporary Partial Disability
g.
Attorney’s Fees and Costs
k.
Interest
c.
Permanent Total Disability
h.
Transportation Costs
l.
Death Benefits – Attach list of
i.
Medical Costs
beneficiaries, including name, age,
d.
Permanent Partial Impairment
State amount requested. $
relationship and address.
e.
Compensation Rate Adjustment - Attach earnings records.
m.
Other – In #20 above, provide details
See brochure Workers’ Compensation & You for more information.
and amount.
22. Claimant’s Name (if other than employee)
23. Telephone
24. Claimant’s Address
City
State
Zip Code
FORM WILL BE RETURNED UNLESS SIGNED BELOW
25. Name of Individual Submitting the Form (print or type)
26. Signature
27. Date
28. Address
City
State
Zip Code
29. Telephone
FILE WITH ALASKA WORKERS’ COMPENSATION BOARD
07-6106 (Rev 10/2016)
Page 1 of 1
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