Alaska > Workers Comp
Request For Conference 07-6135 - Alaska
| Request For Conference Form. This is a Alaska form and can be used in Workers Comp . |
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ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Alaska Workers' Compensation Board P.O. Box 115512, Juneau AK 99811-5512 REQUEST FOR CONFERENCE AWCB Case Number: Use this form to request a prehearing or settlement conference. It may be filed only after a "Workers' Compensation Claim" (Form 07-6106) or "Petition" (form 07-6111) has been filed. I. Attach a completed "Medical Summary" (form 07-6103) if you have new medical reports since you filed your last Medical Summary. II. If you want to raise additional issues not listed on your original Claim/Petition, an amended form MUST be attached. 1. Employee's Name (Last, First, Middle Initial) 3. Address City 6. Employer 8. Employer Address City State Zip Code Telephone State Zip Code Telephone 2. Date of Injury 4. Social Security Number 5. Date of Birth 7. Insurer/Adjusting Company 9. Insurer Address City State Zip Code Telephone 10. Please schedule a (CHOOSE ONE) Anchorage 3301 Eagle Street, Suite 304 Anchorage AK 99503 Reason for Prehearing: 11. Employee's claim was controverted: Prehearing Conference or a Mediation in: Fairbanks 675 7th Avenue, Station K Fairbanks, AK 99701-4593 Yes No Yes No Juneau P.O. Box 115512, Juneau AK 99811-5512 1111 W 8th Street, Suite 307, Juneau AK 99801 Date Controversion Notice filed: Weekly Rate $ 12. Employee is now receiving compensation payments: 13. List the dates you will be available for a conference in the next 30 days: 14. Attorney's Name and Firm Name (if represented) 15. Attorney Address 16. Name of Person Submitting Form (Print or Type) 18. Address City State Zip Code Telephone 17. Signature City State Zip Code Telephone 19. PROOF OF SERVICE: I certify that on the date in #22 below, I mailed/delivered a true and correct copy of this request to the following (request will be returned with no action if all parties are not served): a. The employee in #1 above at the address in #3. b. The employer in #6 above at the address in #8. c. The insurer in #7 above at the address in #9. d. Other (State name and address): Name Name 20. Name of Person Serving Request Form 07-6135 (Rev 11/2011) Address Address 22. Date 21. Signature American LegalNet, Inc. www.FormsWorkFlow.com
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