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

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)