Petition {07-6111}

ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Alaska Workers' Compensation Board P.O. Box 115512, Juneau AK 99811-5512 Petition (Do Not Use As A Claim For Benefits) AWCB Case Number: workerscomp@alaska.gov To the Person Receiving this Petition: You have 20 days after the date this petition was served on you to respond in writing or ask for a hearing before the Alaska Workers' Compensation Board (AWCB). Your response to this petition must be filed with the AWCB, and it must show that a copy was given to the person who submitted this petition (see #21 below). If you have an attorney and you have questions, contact your attorney. If you do not have an attorney and you have questions, contact the AWCB. 1. Employee's Name (Last, First, Middle Initial) 4. Address City 7. Employer 9. Address City State Zip Code Telephone State Zip Code Telephone 8. Insurer 10. Address City State Zip Code Telephone 2. Insurer Claim Number 3. Date of Injury 5. Social Security No. 6. Date of Birth PETITION TYPE ­ CHECK APPROPRIATE BOXES. 11. 12. 13. PROTECTIVE ORDER COMPEL DISCOVERY CONTINUE OR CANCEL HEARING 16. RECONSIDERATION OR MODIFICATION SIME - EXAMINATION BY BOARD-SELECTED PHYSICIAN 14. UNDER AS 23.30.095(k) REVIEW OF REEMPLOYMENT BENEFIT DECISION UNDER 15. AS 23.30.041 JOIN ADDITIONAL EMPLOYER(S) AND/OR INSURER(S): 17. Pursuant to 8 AAC 45.040(g), the person or party to be joined as a party will be joined unless within 20 days after the service of this petition the person or party files an objection with the board and serves the objection on all parties in accordance with 8 AAC 45.060. 18. OTHER: ___________________________________________ REASON FOR PETITION ­ STATE IN DETAIL. ATTACH ADDITIONAL PAGES IF NECESSARY. 19. COMPLETE MEDICAL SUMMARY (Form 07-6103) AND ATTACH IF REQUIRED UNDER 8 AAC 45.052. 20. PROOF OF SERVICE: I certify that on the date in #23 below I served a true and correct copy of this petition on the following (your petition will be returned if you do not show service to all parties and employers/insurers sought to be joined): a. c. The employee in #1 at the address in #4. The insurer in #8 at the address in #10. b. d. The employer in #7 at the address in #9. Other (State Name and Address): _____________________________________ _____________________________________ _____________________________________ FORM WILL BE RETURNED UNLESS SIGNED BELOW 21. Name of Individual Filing this Form (Print or Type) 24. Address 22. Signature City State 23. Date Zip Code FILE WITH ALASKA WORKERS' COMPENSATION BOARD Form 07-6111 (Rev 07/2016) American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 1