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Division of Workers' Compensation
State of Alaska > DOLWD > Workers' Compensation

List of Workers' Compensation Forms

Forms are in Adobe Acrobat © (PDF) and Microsoft Word © (.DOC) Format

You may view and print any of the following PDF documents with Adobe® Acrobat® Reader. This is free software that can be downloaded from the Adobe web site. For information about this process, click here.

NOTE:  Employers, please contact your Insurer or Claims Administrator for your method of reporting injuries.

Affidavit of Compensation Rate Less Than $154 (Form 07-6175)

Affidavit of Readiness for Hearing (Form 07-6107)

Claim for Benefits (Form 07-6106)

Compensation Report, Effective 07/22/2013 (Form 07-6104b)

Compromise and Release Agreement Summary (Form 07-6117)

Controversion (Denial) Notice, Effective 07/22/2013 (Form 07-6105)

Controversion (Denial) Notice, Non-EDI form (Form 07-6105n)

Death Benefits Report (Form 07-6118)

EDI, Instructions for Use of Claims R3 Forms (Form 07-61XX)

EDI Crosswalk, Compensation Report (Form 07-6104b)

EDI Crosswalk, Controversion (Denial) Notice (Form 07-6105)

EDI Crosswalk, Employee Report of Occupational Injury or Illness to Employer (Form 07-6100)

EDI Crosswalk, Employer Report of Occupational Injury or Illness to Division of Workers’ Compensation (Form 07-6101)

Employee Report of Occupational Injury or Illness to Employer, Effective 07/22/2013 (Form 07-6100)

Employer Report of Occupational Injury or Illness to Division of Workers’ Compensation, Effective 07/22/2013 (Form 07-6101)

Employers' Notice of Insurance (Form 07-6120)

Executive Officer Waiver, Instructions & Form for Executive Officer Waiver (Form 07-6131)

Firefighter’s Lung & Heart Physical Examination and Cancer Screening (Form 07-6177)

Firefighter’s Medical History & Evaluation (Form 07-6176)

Fishermen’s Fund, Carpal Tunnel Syndrome Questionnaire (Form 07-6123)

Fishermen’s Fund, Claim Form (Form 07-6125)

Fishermen’s Fund, Compelling Reasons Questionnaire (Form 07-6124)
(Also available in Microsoft Word)

Fishermen’s Fund, Medical and Related Transportation or Other Expenses

Fishermen’s Fund, Physician's Report (Form 07-6126)

Fishermen’s Fund, Report of Vessel/Site Insurance (Form 07-6119)
(Also available in Microsoft Word)

Fisherman's Fund, Request for Release of Information (Form 07-6133)

Fishermen’s Fund, Vessel Owner (Employer) – Crewman Agreement

Medical Summary (Form 07-6103)

Notice of Appearance (Form 07-6116)

Notice of Intent to Rely (Form 07-6114)

Petition (Form 07-6111)

Physician's Report (Form 07-6102)

Public Records Request (Form 07-6122)

Reemployment, Application to Provide Reemployment Services as a Rehabilitation Specialist Under AS 23.30.041 (Form 07-6166)

Reemployment, Eligibility Evaluation Checklist (Form 07-6150)
(Also available in Microsoft Word)

Reemployment, Employer Notice of 45 Consecutive Days of Time Loss for Injuries
(Form 07-6170)

Reemployment, Employer Notice of 90 Consecutive Days of Time Loss for Injuries
(Form 07-6169)

Reemployment, Guide for Preparing Reemployment Benefits Eligibility Evaluations
(Form 07-6161)

Reemployment, Offer of Alternative Employment (Form 07-6151)
(Also available in Microsoft Word)

Reemployment, Reemployment Benefits Plan Checklist (Form 07-6171)

Reemployment, Stipulation to Eligibility for Injuries (Form 07-6152)

Reemployment, Waiver of Reemployment Benefits (Form 07-6168)
(Also available in Microsoft Word)

Release of Counseling, Psychological, Psychiatric, or Alcohol/Drug/Substance
Abuse Treatment Records or Information

Release of Medical Information (Form 07-6146) (Rev. 05/13/2011)

Request for Conference (Form 07-6135)
(Also available in Microsoft Word)

Request for Cross-examination (Form 07-6174)

Request for Release of Information (Form 07-6121)

Second Independent Medical Evaluation (SIME) (Form 07-6147)

Second Injury Fund, Notice of Possible Claim Against The Second Injury Fund
(Form 07-6110)

Second Injury Fund, Petition to Join Second Injury Fund and Claim for Reimbursement
(Form 07-6109)

Self-Insurance, Application for Certificate of Self-Insurance (Form 07-6129)

Self-Insurance, Parent Company Guarantee

Self-Insurance, Renewal of Certificate of Self-Insurance (Form 07-6130)

Special Investigations Brochure (Form WCD-005)

Subpoena (Form 07-6112)


 

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Contact Information:
TEL:
(907) 465-2790
FAX:
(907) 465-2797
   

Address:
PO Box 115512
Juneau, AK 99811-5512

 
Toll Free:
1-877-783-4980

 

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Page Updated July 22, 2014