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.
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) [PDF]
Affidavit of Complete SIME Records (Form 07-6148) [PDF]
Affidavit of Readiness for Hearing (Form 07-6107) [PDF]
Change of Address (Form 07-6138) [PDF]
(Also available in Microsoft Word) [DOC]
Claim for Benefits (Form 07-6106) [PDF]
Compensation Report (Form 07-6104b) [DOC]
Compensation Report - Legacy Claims (Form 07-6104b - Legacy Claims) [DOC]
Compromise and Release Agreement Summary (Form 07-6117) [PDF]
Controversion (Denial) Notice (Form 07-6105) [DOC]
Death Benefits Report (Form 07-6118) [PDF]
EDI, Instructions for Use of Claims R3 Forms (Form 07-61XX) [DOCX]
Employee Report of Occupational Injury or Illness to Employer, Effective 07/22/2013 (Form 07-6100) [DOC]
Employer Report of Occupational Injury or Illness to Division of Workers’ Compensation (Form 07-6101) [DOC][updated 03/2015]
Employers' Notice of Insurance (Form 07-6120) [PDF]
Firefighter’s Lung & Heart Physical Examination and Cancer Screening (Form 07-6177) [DOC]
Firefighter’s Medical History & Evaluation (Form 07-6176) [DOC]
Fishermen’s Fund, Claim Form (Form 07-6125) [PDF]
Fishermen’s Fund, Compelling Reasons Questionnaire (Form 07-6124) [PDF]
(Also available in Microsoft Word) [DOC]
Fishermen’s Fund, Medical and Related Transportation or Other Expenses [PDF]
Fishermen’s Fund, Physician's Report (Form 07-6126) [PDF]
Fishermen’s Fund, Report of Vessel/Site Insurance (Form 07-6119) [PDF]
(Also available in Microsoft Word) [DOC]
Fisherman's Fund, Request for Release of Information (Form 07-6133) [PDF]
Fishermen’s Fund, Vessel Owner (Employer) – Crewman Agreement [PDF]
Medical Summary (Form 07-6103) [PDF]
Also available in Word format [DOCX]
Notice of Appearance (Form 07-6116) [PDF]
Notice of Intent to Rely (Form 07-6114) [PDF]
Petition (Form 07-6111) [PDF]
(Also available in Microsoft Word) [DOC]
Physician's Report (Form 07-6102) [PDF]
Public Records Request (Form 07-6122) [PDF]
Reemployment, Application to Provide Reemployment Services as a Rehabilitation Specialist Under AS 23.30.041 (Form 07-6166) [PDF]
Reemployment, Election to Either Receive Reemployment Benefits OR Waive Reemployment Benefits and Receive a Job Dislocation Benefit Instead (Form 07-6153) [PDF]
Reemployment, Eligibility Evaluation Checklist (Form 07-6150) [PDF]
(Also available in Microsoft Word) [DOC]
Reemployment, Employer Notice of 45 Consecutive Days of Time Loss for Injuries
(Form 07-6170) [PDF]
Reemployment, Employer Notice of 90 Consecutive Days of Time Loss for Injuries
(Form 07-6169) [PDF]
Reemployment, Guide for Preparing Reemployment Benefits Eligibility Evaluations
(Form 07-6161) [PDF]
Reemployment, Offer of Alternative Employment (Form 07-6151) [PDF]
(Also available in Microsoft Word) [DOC]
Reemployment, Reemployment Benefits Plan Checklist (Form 07-6171) [PDF]
Reemployment, Stipulation to Eligibility for Injuries (Form 07-6152) [PDF]
Reemployment, Waiver of Reemployment Benefits (Form 07-6168) [PDF]
(Also available in Microsoft Word) [DOC]
Release of Medical Information (Form 07-6146) (Rev. 05/13/2011) [PDF]
Request for Conference (Form 07-6135) [PDF]
(Also available in Microsoft Word) [DOC]
Request for Cross-examination (Form 07-6174) [PDF]
Request for Release of Information (Form 07-6121) [PDF]
(Also available in Microsoft Word) [DOC]
Second Independent Medical Evaluation (SIME) (Form 07-6147) [PDF]
Self-Insurance, Application for Certificate of Self-Insurance (Form 07-6129) [PDF]
(Also available in Microsoft Word) [DOCX]
Self-Insurance, Parent Company Guarantee
Self-Insurance, Renewal of Certificate of Self-Insurance (Form 07-6130) [PDF]
(Also available in Microsoft Word) [DOCX]
Special Investigations Brochure (Form WCD-005) [PDF]
Subpoena (Form 07-6112)
