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This is a Alaska form that can be used for Workers Comp.
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EMPLOYER'S NOTICE OF INSURANCE TO THE EMPLOYEES OF THE UNDERSIGNED: Your employer is insured by: Insurer Street and Number City For the period from Through State Zip Code Adjusting Company Street and Number City State Zip Code Telephone This insurance pays benefits for job-connected injuries, illnesses or death as provided by the Alaska Workers' Compensation Act Employer By Title Witness Witness Immediately (not later than 30 days from injury or death date) give your employer and the Alaska Workers' Compensation Division written notice of a job-related injury, illness, or death. Get the "Report of Occupational Injury or Illness" form from your employer for this purpose If you have questions about your rights or benefits under the Alaska Workers' Compensation Act, contact the insurer at the above address and the Alaska Workers' Compensation Division at the nearest office listed below: ANCHORAGE 3301 Eagle Street Suite 304 Anchorage AK 99503 (907) 269-4980 FAIRBANKS 675 7th Ave Station K Fairbanks AK 99701-4531 (907) 451-2889 JUNEAU PO Box 115512 1111 W 8th St Rm 305 Juneau AK 99811-5512 (907) 465-2790 NOTICE TO EMPLOYER: AS 23.30.060 requires that you post this notice in three conspicuous places on the employer's premises. Form 07-6120 (Rev 05/2012) American LegalNet, Inc. www.FormsWorkFlow.com