Alaska > Workers Comp
Compensation Report 07-6104B - Alaska
| Compensation Report Form. This is a Alaska form and can be used in Workers Comp . |
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your information. Keep it for EMPLOYEE: This report is forinformation about your rights your records. Read important on back. ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Alaska Workers' Compensation Board P.O. Box 115512, Juneau AK 99811-5512 1. Employee's Name (Last, First, Middle Initial) 4. Address City 8. Employer 10. Address City State Zip Code Telephone State Zip Code Telephone AWCB Case Number Only COMPENSATION REPORT 2. Insurer Claim Number 5a. Single 5b. Number of Dependents Married (AWCB Use Only) 9. Insurer/Adjusting Company 11. Address City State Zip Code 3. Injury Date 6. Social Security Number 7. Birth Date Telephone 12. COMPENSATION RATE --COMPLETE FOR INITIAL PAYMENT OR RATE CHANGE Employee's wages were calculated: a. Weekly = $ (weekly earnings) gross weekly earnings at time of injury (attach wage documents). (monthly earnings) x 12/52 = (yearly earnings) ÷ 52 = $ $ gross weekly earnings (attach wage documents). gross weekly earnings (attach wage documents). $ b. Monthly = $ c. Yearly = $ d. Day, hour, or output = earnings during either of the two calendar years immediately preceding the injury, whichever is most favorable to the employee gross weekly earnings (attach wage documents). e. Worked less than 13 calendar weeks immediately before injury = $ f. Wages not fixed at time of injury, explain how earnings determined: g. By the week or by the month, and employment is exclusively Seasonal/Temporary: = earnings for 12 calendar months immediately preceding date of injury $ h. 2 employers or more, use applicable methods above. i. Minor, apprentice, or trainee. j. Volunteer policeman, etc. 13. a. Alaska TTD, PTD, Death b. Gross Earnings k. Offset: Social Security (#39) or 155(i) (#40) (attach wage documents). l. Paid $110 minimum, explain Gross Weekly Earnings - Tax & FICA x 80% = d. Weekly TTD Rate c. Alaska TPD Offset 41K e. Out-of-state TTD, PTD, Death f. Alaska TTD Rate 14. a. INITIAL PAYMENT g. RESUMPTION 15. a. Payment Date b. SIF PAYMENT ONLY Knowledge Date: b. Type Weekly Earnings Capacity -( COLA Ratio x c. TERMINATION h. OTHER (Explain) c. From d. Through e. Weeks & Days - Tax & FICA x 80% = )= earnings ÷ 13 = $ ÷ 50 = $ gross weekly earnings (attach wage documents). ÷ 50 = gross weekly earnings; Weekly Rate* Weekly Rate* Maximum or Minimum Maximum or Minimum d. SUSPENSION COLA Weekly Rate Date Left Alaska %= e. RATE CHANGE f. TYPE CHANGE f. Weekly Rate g. Total Amount (If additional space is needed, use chart on reverse.) 16. Impairment Rating: 17. % of $177,000 Whole Person = $ TOTAL Permanent impairment compensation was paid in a lump sum. (Enter amount in No. 15 and 16.) If permanent impairment benefits not paid in a lump sum, enter date Employee requested reemployment benefits. Date: 20. TURN OVER AND COMPLETE ITEM 20 ON REVERSE. 18. a. Date Disability Began b. First Payment Date 19. Date Disability Ended REASON FOR SUSPENSION, TERMINATION, RATE CHANGE, TYPE CHANGE, OR NONPAYMENT. 21. Returned to Work At New Job Occupation Weekly Pay Rate $ Date: At Same Job 22. Released for Work Date: Regular Work Modified Work 23. 25. 27. 29. 31. Signature City Medical Stability C.O.L.A. Recomputation Other 24. 26. 28. Compromise and Release Controversion (Attach 07-6105) Board Order I certify that I have mailed the original of this report to the employee at the address above and a copy to the Alaska Workers' Compensation Board 30. Name and Title of Person Submitting Report (Type or Print) 33. Address (If Different From No. 11) 32. Date State Zip Code Telephone * From AWCB Tables American LegalNet, Inc. www.FormsWorkFlow.com Form 07-6104b (Rev 04/2011) EXPLANATIONS AND INSTRUCTIONS ON BACK 34. Employee's Name (Last, First, Middle Initial) 20. a. Employee Attorney Fees $ d. Medical $ g. Reemployment $ i. Other (Explain) 36. a. Payment Date b. Type c. From d. Through e. Weeks & Days b. Late Report Penalties $ e. Second Injury Fund $ SIF Check Attached c. Employer Attorney Fees $ f. Reemployment Plan Cost $ h. Interest $ $ f. Weekly Rate 35. Report Date g. Total Amount FRONT PAGE TOTAL TOTAL 37. SOCIAL SECURITY OFFSET. (Applies only to some recipients of Social Security Benefits.) a. Social Security Retirement or Survivors Benefits (AS 23.30.225(a)). How the reduced weekly compensation was figured: (1) SS Monthly Benefit SS Weekly Benefit Reduction (2) Weekly Rate x 12/52 = x 1/2 = b. Social Security Disability Benefits (AS 23.30.225(b)). How the reduced weekly compensation rate was figured: (1) SS Monthly Benefit SS Weekly Benefit (2) Gross Weekly Earnings Max. Weekly Payment x 12/52 = x 80% = 38. Remarks Reduction SS Weekly Benefit = = Reduced Weekly Rate Reduced Weekly Rate 39. EXPLANATION AND ABBREVIATIONS a. b. c. Suspension. Item 14d means the employer/insurer has stopped compensation payments expecting to pay more compensation later (usually the difference between the minimum and the documented rate). See paragraph 40a below for effect on medical benefits. Termination. Item 14c means the employer/insurer has stopped compensation payments with the belief all compensation due has been paid. See paragraph 40a below for effect on medical benefits. In Item 15b, the following abbreviations means the following types of disability: Dth = Death Benefits (Attach 07-6118) TTD = Temporary Total Disability TPD = Temporary Partial Disability PTD = Permanent Total Disability PPI = Permanent Partial Impairment 41 K = Reemployment 25% = 25% Late Payment Penalty d. e. Knowledge Date under Item 14g means the date the employer/insurer learned about the employee's resumed disability or PPI rating. SIF in Items 14b and 20e means Second Injury Fund. The insurer/employer makes this payment directly to the Alaska SIF, not the employee. SIF payments must be attached to the Board's annual report. The SIF payment does not affect the amount of compensation an employee receives. 40. TO EMPLOYEE (or other claimants in the case of death): READ CAREFULLY a. This report means the insurer/employer has begun, stopped or changed your compensation payments. The insurer/employer should continue to pay for medical treatment for your injury for at least two years after your injury date. Although the law lets the insurer/employer stop medical payments two years after your injury date, you may file a written claim asking the Alaska Workers' Compensation (AWC) Board to authorize additional medical payments for treatment necessary to your recovery. b. YOU HAVE TWO YEARS FROM THE DATE OF THE COMP
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