Form 08-6106 "Claim for Workers' Compensation Benefits" - Alaska

What Is Form 08-6106?

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 December 1, 2017;
  • 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 fillable version of Form 08-6106 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 08-6106 "Claim for Workers' Compensation Benefits" - Alaska

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ALASKA DEPARTMENT OF LABOR &
AWCB Case Number:
WORKFORCE DEVELOPMENT
CLAIM FOR
Division of Workers’ Compensation
WORKERS’ COMPENSATION BENEFITS
P.O. Box 115512, Juneau, AK 99811-5512
Fax: (907) 465-2797
workerscomp@alaska.gov
This Claim form is used to request benefits an employer has not paid and to which you believe you are entitled. It should be filed only after the employer has reported the employee’s injury
to the Division by filing a Report of Injury form. If the employer refuses to file or is unavailable to complete a Report of Injury form, please contact the Division.
1. Employee’s Name (Last, First, Middle Initial)
2. Insurer Claim Number
3. Injury Date
4. Address
City
State
Zip Code
5. City/Town/Village Where Injury Occurred
6. Social Security No.
7. E-Mail Address (if available)
Telephone
8. Occupation
9. Date of Birth
10. Name and Office of Employee’s Attorney (if no attorney, leave blank)
11. Employer at Time of Injury
12. Attorney’s Address (No., Street, City, State & Zip Code)
13. Employer Address (No., Street, City, State & Zip Code)
14. Attorney’s Telephone No.
15. Insurer/Adjusting Company
16. Attorney’s E-mail Address (Required)
17. Insurer/ Adjuster Address (No., Street, City, State & Zip Code)
18. Claim against the Benefits Guaranty Fund. Applies ONLY if the employer was NOT insured for workers’ compensation liability on the date of
injury (the Division will verify employer’s coverage.) If the employer (box 11) was uninsured for workers’ compensation liability on the date of injury and
failed to pay its employee (box 1) benefits due under the Alaska Workers’ Compensation Act, are you also filing against the Fund?
YES
NO
19. Describe the nature of the injury or illness, how the injury or illness happened, and part of body injured. Attach additional pages if necessary:
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
20. Reason for filing claim (be specific): _______________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
21. CLAIM IS MADE FOR:
a.
Temporary Total Disability
f.
Unfair or Frivolous Controversion (Denial)
j.
Penalty for Late Paid Compensation
b.
Temporary Partial Disability
g.
Attorney’s Fees and Costs
k.
Interest
c.
Permanent Total Disability
h.
Transportation Costs
l.
Death Benefits – Attach list of
i.
Medical Costs (state amount
beneficiaries, including name, age,
d.
Permanent Partial Impairment
requested) $
relationship and address.
e.
Compensation Rate Adjustment - Attach earnings records.
m.
Other (Give details and amount
See brochure Workers’ Compensation & You for more information.
requested in #20 above)
22. Claimant’s Name (if other than employee)
23. Telephone
24. Claimant’s Address
City
State
Zip Code
FORM WILL BE RETURNED UNLESS SIGNED BELOW
25. Name of Individual Submitting the Form (print or type)
26. Signature
27. Date
28. Address
City
State
Zip Code
29. Telephone
FILE WITH ALASKA WORKERS’ COMPENSATION BOARD
 
07-6106 (Rev 12/2017)
Page 1 of 1
ALASKA DEPARTMENT OF LABOR &
AWCB Case Number:
WORKFORCE DEVELOPMENT
CLAIM FOR
Division of Workers’ Compensation
WORKERS’ COMPENSATION BENEFITS
P.O. Box 115512, Juneau, AK 99811-5512
Fax: (907) 465-2797
workerscomp@alaska.gov
This Claim form is used to request benefits an employer has not paid and to which you believe you are entitled. It should be filed only after the employer has reported the employee’s injury
to the Division by filing a Report of Injury form. If the employer refuses to file or is unavailable to complete a Report of Injury form, please contact the Division.
1. Employee’s Name (Last, First, Middle Initial)
2. Insurer Claim Number
3. Injury Date
4. Address
City
State
Zip Code
5. City/Town/Village Where Injury Occurred
6. Social Security No.
7. E-Mail Address (if available)
Telephone
8. Occupation
9. Date of Birth
10. Name and Office of Employee’s Attorney (if no attorney, leave blank)
11. Employer at Time of Injury
12. Attorney’s Address (No., Street, City, State & Zip Code)
13. Employer Address (No., Street, City, State & Zip Code)
14. Attorney’s Telephone No.
15. Insurer/Adjusting Company
16. Attorney’s E-mail Address (Required)
17. Insurer/ Adjuster Address (No., Street, City, State & Zip Code)
18. Claim against the Benefits Guaranty Fund. Applies ONLY if the employer was NOT insured for workers’ compensation liability on the date of
injury (the Division will verify employer’s coverage.) If the employer (box 11) was uninsured for workers’ compensation liability on the date of injury and
failed to pay its employee (box 1) benefits due under the Alaska Workers’ Compensation Act, are you also filing against the Fund?
YES
NO
19. Describe the nature of the injury or illness, how the injury or illness happened, and part of body injured. Attach additional pages if necessary:
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
20. Reason for filing claim (be specific): _______________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
21. CLAIM IS MADE FOR:
a.
Temporary Total Disability
f.
Unfair or Frivolous Controversion (Denial)
j.
Penalty for Late Paid Compensation
b.
Temporary Partial Disability
g.
Attorney’s Fees and Costs
k.
Interest
c.
Permanent Total Disability
h.
Transportation Costs
l.
Death Benefits – Attach list of
i.
Medical Costs (state amount
beneficiaries, including name, age,
d.
Permanent Partial Impairment
requested) $
relationship and address.
e.
Compensation Rate Adjustment - Attach earnings records.
m.
Other (Give details and amount
See brochure Workers’ Compensation & You for more information.
requested in #20 above)
22. Claimant’s Name (if other than employee)
23. Telephone
24. Claimant’s Address
City
State
Zip Code
FORM WILL BE RETURNED UNLESS SIGNED BELOW
25. Name of Individual Submitting the Form (print or type)
26. Signature
27. Date
28. Address
City
State
Zip Code
29. Telephone
FILE WITH ALASKA WORKERS’ COMPENSATION BOARD
 
07-6106 (Rev 12/2017)
Page 1 of 1