Form 07-6169 "Employer's Notice of 90 Consecutive Days of Time Loss for Injuries" - Alaska

What Is Form 07-6169?

This is a legal form that was released by the Alaska Department of Labor and Workforce Development - a government authority operating within Alaska. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2015;
  • The latest edition provided by the Alaska Department of Labor and Workforce Development;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 07-6169 by clicking the link below or browse more documents and templates provided by the Alaska Department of Labor and Workforce Development.

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Download Form 07-6169 "Employer's Notice of 90 Consecutive Days of Time Loss for Injuries" - Alaska

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Alaska Department of Labor and Workforce Development
Division of Workers’ Compensation, Reemployment Benefits Section
3301 Eagle Street, Suite 301, Anchorage, Alaska 99503-4149
Telephone: 907.269.4985 – Fax: 907.334.2619
EMPLOYER’S NOTICE OF
90 CONSECUTIVE DAYS OF TIME LOSS FOR INJURIES
OCCURRING ON OR AFTER NOVEMBER 7, 2005
AWCB Case No.:
Date of Injury:
Employee's Name (Last, First, Middle Initial)
Insurer/Adjusting Company
Address:
Address:
City
State Zip Code
Telephone City
State Zip Code
Telephone
1
, this serves as the employer’s notification that the above
In accordance with 8 AAC 45.507(b)
2
to return to the employee’s employment at the time of injury
3
employee has been totally unable
for 90
consecutive days as a result of the injury.
The 90 consecutive days began on
/ / .
Date:
Signature: ___________________________________
Title:
Printed Name:
Submit to:
Reemployment Benefits Section
3301 Eagle Street, Suite 301
Anchorage, Alaska 99503-4149
1
8 AAC 45.507(b) reads in part: “If the employee has been totally unable to return to the employee’s employment at the time of injury
for 90 consecutive days, as a result of the injury, the employer shall notify the administrator, in writing, on the 91st day.”
2
8 AAC 45.900(i)(2) reads: “‘totally unable’ means the employee has not been released by the attending physician to return to the
employee’s employment at the time of injury on either a modified or unmodified basis’”
3
8 AAC 45.900(i)(1) reads: “‘employment at the time of injury’ means the employee’s essential job duties and tasks, including the
physical requirements of the duties and tasks, that the employee performed at the time of injury’”
Form 07-6169 (Rev 02/2015)
Alaska Department of Labor and Workforce Development
Division of Workers’ Compensation, Reemployment Benefits Section
3301 Eagle Street, Suite 301, Anchorage, Alaska 99503-4149
Telephone: 907.269.4985 – Fax: 907.334.2619
EMPLOYER’S NOTICE OF
90 CONSECUTIVE DAYS OF TIME LOSS FOR INJURIES
OCCURRING ON OR AFTER NOVEMBER 7, 2005
AWCB Case No.:
Date of Injury:
Employee's Name (Last, First, Middle Initial)
Insurer/Adjusting Company
Address:
Address:
City
State Zip Code
Telephone City
State Zip Code
Telephone
1
, this serves as the employer’s notification that the above
In accordance with 8 AAC 45.507(b)
2
to return to the employee’s employment at the time of injury
3
employee has been totally unable
for 90
consecutive days as a result of the injury.
The 90 consecutive days began on
/ / .
Date:
Signature: ___________________________________
Title:
Printed Name:
Submit to:
Reemployment Benefits Section
3301 Eagle Street, Suite 301
Anchorage, Alaska 99503-4149
1
8 AAC 45.507(b) reads in part: “If the employee has been totally unable to return to the employee’s employment at the time of injury
for 90 consecutive days, as a result of the injury, the employer shall notify the administrator, in writing, on the 91st day.”
2
8 AAC 45.900(i)(2) reads: “‘totally unable’ means the employee has not been released by the attending physician to return to the
employee’s employment at the time of injury on either a modified or unmodified basis’”
3
8 AAC 45.900(i)(1) reads: “‘employment at the time of injury’ means the employee’s essential job duties and tasks, including the
physical requirements of the duties and tasks, that the employee performed at the time of injury’”
Form 07-6169 (Rev 02/2015)