Alaska > Workers Comp
Report Of Occupational Injury Or Illness 07-6101 - Alaska
| Report Of Occupational Injury Or Illness Form. This is a Alaska form and can be used in Workers Comp . |
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ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Division of Workers' Compensation P.O. Box 115512, Juneau AK 99811-5512 REPORT OF OCCUPATIONAL INJURY OR ILLNESS Initial 2. Telephone Number 7. Residence Address 3. Date of Birth AWCB Case Number (Division Use Only): EMPLOYEE: 1. Last Name 6. Mailing Address 6a. City First Name Answer ALL questions 1 - 20, sign, and give to your employer immediately. 4. Sex M F 5. Social Security Number State Zip Code 7a. City 9. Date of Injury or Exposure to Disease State Zip Code 8. Place (City/Town/Village/Camp) Where Injury/Occupational Illness Happened 11. Name & Address of Attending Physician City State Zip Code Left Right 10. On Employer's Premises? YES NO 12. Hospitalization In-Patient? 13. Name of Hospital YES NO City State Zip Code 14. Describe Part(s) of Body Injured / Nature of Occupational Illness 15. Describe How the Injury or Occupational Illness Happened 16. To all health care providers: You are authorized to provide my employer (named in box 18), its workers' compensation liability insurance company (box 21), and its claims adjuster (box 22) information concerning any health care advice, testing, treatment, or supplies provided to me for the injury or illness described above in box 14. This information will be used to evaluate my entitlement to receive benefits, including payment of medical benefits, under the Alaska Workers' Compensation Act. This authorization is valid for a one-year period from the date of my signature (box 17a). I know I have a right to receive a copy of this authorization and agree a photographic copy of this authorization is as valid as the original. Employee/Patient's Signature: 17. If Employee Unavailable for Signature, Explain Circumstances in this Space 17a. Date Signed EMPLOYER: 18. Employer's Name 20. Employer's Mailing Address (Street and Number) 20a. City 23. Date Employer First Knew of Injury State Review employee answers 18 - 20, answer questions 21 - 49. 19. Employer's Alaska Address (If Different from Mailing) 21. Name of Insurer Zip Code 20b. Telephone 22. Full Name and Address of Adjusting Company 22a. Mailing Address (Street and Number) N 22b. City 29. Employee's Occupation 33. Days Employee Works per Week 6 5 4 3 or Less 34. Describe Scheduled Days Off 7 State Zip Code 22c. Telephone 30. Date Hired By Employer 24. Date/Time (AM / PM) Employee Left Work Y 25. Off Work After Injury / Illness? 26. Date Returned to Work 27. Death? YES Date NO 3 or More Days? 28. Location Where Injury or Occupational Illness Happened 31. Earnings Calculated By Output Day Hr. 32. Rate of Pay Yr. $ per Wk. Mo. 37. Federal EIN # 35. Workday Began 36. Employee Paid for Day NO PM Injured or Ill? YES AM 38. Give Details of How Injury or Illness Happened 39. Injury / Illness Due to Machine / 40. Mechanical Guard / Safeguards 41. List Any Machine / Substance / Object Causing Injury Product Failure? YES NO Provided? YES NO 43. Name and Address of Witnesses 42. If Machine,What Part? 44. If Injury / Illness Caused by Anyone Besides Employee, Give Name and Address 45. Dependents (in case of death), Names and Addresses 46. If You Doubt Validity of Injury or Illness, State Reason 47. Signature of Authorized Employer or Representative 48. Title 49 Date Signed WARNING TO EMPLOYEES AND EMPLOYERS: AS 23.30.250 imposes civil penalties for fraud as well as certain false or misleading statements and acts. Criminal penalties for theft by deception (including fines and incarceration) apply to knowingly made false statements, claims, or employee misclassifications. Distribution: Original -Workers' Compensation Division; Copy -Adjuster; Copy -Employer; Copy -Employee American LegalNet, Inc. www.FormsWorkFlow.com Form 07-6101 (Rev 08/2012) Instructions for REPORT OF OCCUPATIONAL INJURY OR ILLNESS TO THE EMPLOYEE You must complete and sign the "EMPLOYEE" section, questions 1-17, and answer questions 18-20 in the "EMPLOYER" section of this form. Keep a copy for your records. Immediately give this form to your employer. The employer will then complete their portion, and forward copies to their insurer, their claims administrator, and the Workers' Compensation Division. You should notify your employer immediately, but no later than 30 days after your injury occurred or illness began. After obtaining medical treatment, tell your health care provider's office to complete and mail the required "Physician's Report" (form 07-6102) to your employer's insurer for payment and to the Workers' Compensation Division for your file. A completed report is a requirement for payment under AS 23.30.095 (c). If you, your employer, and your doctor promptly file the required reports, there should be no delay in payment of compensation. You will not be paid compensation for lost wages for the first three days off work unless your disability lasts more than 28 days. The first installment of compensation becomes due on the 14th day after the employer has knowledge of the injury, illness or disease. After the first payment, you should get a check every two weeks while you are disabled. If you have not received payment within 21 days from the date you were injured or became ill, contact the insurer or adjuster first. If you have any questions or problems, contact the Workers' Compensation Division office nearest you (contact information listed below). If you are off work for 3 or more days, you will need to provide additional information to your employer's claims adjuster regarding your wages, marital status, and number of dependents. If you believe your work related injury or illness will keep you from returning to your job at the time of injury, you may need retraining. The training benefits to which you may be entitled, and how you go about getting them, depend on your date of injury. If you are off work for 45 days, contact the division office in Anchorage to learn more about your rights for reemployment benefits. You may also refer to the Reemployment Benefits section of the "Workers' Compensation and You" brochure available at the Division's internet web page: www.labor.state.ak.us/wc INFORMATION IN FILES MAINTAINED BY THE DIVISION OF WORKERS' COMPENSATION, EXCEPT FOR MEDICAL AND REHABILITATION RECORDS IS AVAILABLE FOR PUBLIC REVIEW AND COPYING FOR NONCOMMERCIAL PURPOSES. AS 23.30.107 TO THE EMPLOYER This form must be completed and mailed immediately, and in no case later than ten days after you have knowledge that your employee has been injured, or claims t
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