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Alaska Form Center -

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Form

Description

6101.pdf Employer Report of Occupational Injury or Illness to Division of Workers' Compensation
6100.pdf Employee Report of Occupational Injury or Illness to Employer
6175.pdf Affidavit of Compensation Rate Less than $154
6107.pdf Affidavit of Readiness for Hearing
6106.pdf Claim for Benefits - Workers' Compensation Claim
6104b.pdf Compensation Report
6104b_legacy.pdf Compensation Report - Legacy Claims
6117.pdf Compromise and Release Agreement Summary
6105.pdf Controversion (Denial) Notice
6118.pdf Death Benefits Report
6131.pdf Executive Officer Waiver - Instructions and Form
6148.pdf Affidavit Verifying SIME Records Are Complete
6177.pdf Firefighter's Lung and Heart Physical Examination and Cancer Screening Form
6176.pdf Firefighter's Medical History and Evaluation Form
6125.pdf Fishermen's Fund Claim Form
6124.pdf Fishermen's Fund Compelling Reasons Questionnaire
6126.pdf Fishermen's Fund, Physician's Report
6119.pdf Fishermen's Fund, Report of Vessel/Site Insurance
6133.pdf Fishermen's Fund, Request for Release of Information
vessel.pdf Vessel Owner (Employer) Crewman Agreement Regarding Medical and Related Transportation or Other Expenses
6103.pdf Medical Summary
6116.pdf Notice of Appearance
6114.pdf Notice of Intent to Rely
6111.pdf Petition
6102.pdf Physician's Report
6122.pdf Public Records Request
6138.pdf Change of Address
6166.pdf Reemployment, Application to Provide Reemployment Services as a Rehabilitation Specialist
6150.pdf Eligibility Evaluation Checklist
6170.pdf Reemployment, Employer Notice of 45 Consecutive Days of Time Loss for Injuries
6169.pdf Reemployment, Employer Notice of 90 Consecutive Days of Time Loss for Injuries
6161.pdf Reemployment, Guide for Preparing Reemployment Benefits Eligibility Evaluations
6153.pdf Reemployment, Election to Either Receive Reemployment Benefits or Waive Reemployment Benefits and Receive a Job Dislocation Benefit Instead
6151.pdf Offer of Alternative Employment
6171.pdf Reemployment Benefits Plan Checklist
6152.pdf Reemployment Stipulation to Eligibility for Injuries
awcb.pdf Waiver of Reemployment Benefits
medrls002.pdf Release of Counseling, Psychological, Psychiatric, or Alcohol/Drug/Substance Abuse Treatment Records or Information
medris001.pdf Release of Medical Information
6135.pdf Request for Conference
6174.pdf Request for Cross-examination
6121.pdf Request for Release of Information
6147.pdf Second Independent Medical Evaluation
6110.pdf Notice of Possible Claim Against the Second Injury Fund
6109.pdf Petition to Join SIF and Claim for Reimbursement
6129.pdf Application for Certificate of Self-Insurance
parent.pdf Parent Company Guarantee
6130.pdf Renewal of Certificate of Self-Insurance
6112.pdf Subpoena
FSA.pdf Financial Statement Affidavit
6120.pdf POSTER - Employers' Notice of Insurance
WC-SIU.pdf BROCHURE - Special Investigations
wc-brochure.pdf BROCHURE - Workers' Compensation and You - Information for Injured Workers