Affidavit Verifying SIME Records Are Complete {07-6148}

ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Alaska Workers' Compensation Board P.O. Box 115512, Juneau AK 99811-5512 AFFIDAVIT VERIFYING SIME RECORDS ARE COMPLETE AWCB Case Number: 1. Employee's Name (Last, First, Middle Initial) 2. Date Received (Board Use Only) 3. Date of Injury 4. Employer 5. Insurer/Adjusting Company 6. HAVING FIRST BEEN DULY SWORN, I STATE a. I am a party to this case. b. I reviewed the medical records in my possession regarding this case. c. The SIME binders contain copies of all the medical records in my possession. d. The supplemental SIME records I filed with the board, if any, are identical to the supplemental SIME records I served on the other parties in this case. 7. Name of Affiant (Print or Type) 8. Affiant's Signature (Sign in Front of Notary) SUBSCRIBED AND SWORN TO BEFORE ME THIS 9. Notary Public in and for the State of 11. Notary Public Signature DAY OF 10. My Commission Expires: , . I certify I mailed the original of this affidavit to the Alaska Workers' Compensation Board and a copy to all parties in this case. 12. Name of Person Mailing Affidavit 13. Signature 14. Date Mailed ATTACH TO SIME BINDERS Form 07-6148 (06/2011) American LegalNet, Inc. www.FormsWorkFlow.com