Form PERS008 "Workers' Compensation Claim and Verification" - Alaska

What Is Form PERS008?

This is a legal form that was released by the Alaska Department of Administration - 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 September 1, 2016;
  • The latest edition provided by the Alaska Department of Administration;
  • 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 PERS008 by clicking the link below or browse more documents and templates provided by the Alaska Department of Administration.

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Download Form PERS008 "Workers' Compensation Claim and Verification" - Alaska

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Workers' Compensation
FOR OFFICE USE ONLY
Claim and Verification
Division of Retirement and Benefits
Juneau: (907) 465-4460
Toll-Free: (800) 821-2251
P.O. Box 110203
TDD: (907) 465-2805
alaska.gov/drb
Juneau, AK 99811-0203
Fax: (907) 465-3086
Name (First, Middle, Last)
Social Security Number
Mailing Address (City, State, ZIP+4)
This is my written request to claim the following periods of Workers’ Compensation as credit in the Alaska Public Employees' Retirement
System (PERS) pursuant to AS 39.35.330(c). I understand that I will be indebted to the PERS for the contributions that I would have
made had I remained an active employee during the period of Workers’ Compensation. The following are the approximate dates I was
on Workers’ Compensation:
Example:
to
to
|
Date WC Began
Date WC Ended
Date WC Began
Date WC Ended
to
to
|
Date WC Began
Date WC Ended
Date WC Began
Date WC Ended
Signature of Member
Date
Note:
EMPLOYER VERIFICATION OF WORKERS’ COMPENSATION
(Only periods of Workers’ Compensation after June 12, 1987, are eligible to claim pursuant to AS 39.35.330(c).)
This is to certify that this employee was unable to work due to: 1) an on-the-job injury; or 2) an occupational illness; and 3) received
benefits under AS 23.30. The following information correctly reflect this member’s particular circumstance:
PERIODS OF WORKERS’ COMPENSATION: (use different lines to separate Workers’ Compensation between calendar years)
1.
to
Date WC Began
Date WC Ended
Hourly Rate
Sched Hours
Hours on Workers'
of Pay
per Week
Compensation
2.
to
Date WC Began
Date WC Ended
Hourly Rate
Sched Hours
Hours on Workers'
of Pay
per Week
Compensation
Signature of Employer Representative
Date
Printed Name of Employer Representative
Phone Number
Note: Use reverse side if more than 2 segments are claimed. Examples of verification of Workers’ Compensation are provided for on
page 3.
PERS008 (Rev. 9/16)
G:/publications/forms/pers/pers008.indd
Workers' Compensation
FOR OFFICE USE ONLY
Claim and Verification
Division of Retirement and Benefits
Juneau: (907) 465-4460
Toll-Free: (800) 821-2251
P.O. Box 110203
TDD: (907) 465-2805
alaska.gov/drb
Juneau, AK 99811-0203
Fax: (907) 465-3086
Name (First, Middle, Last)
Social Security Number
Mailing Address (City, State, ZIP+4)
This is my written request to claim the following periods of Workers’ Compensation as credit in the Alaska Public Employees' Retirement
System (PERS) pursuant to AS 39.35.330(c). I understand that I will be indebted to the PERS for the contributions that I would have
made had I remained an active employee during the period of Workers’ Compensation. The following are the approximate dates I was
on Workers’ Compensation:
Example:
to
to
|
Date WC Began
Date WC Ended
Date WC Began
Date WC Ended
to
to
|
Date WC Began
Date WC Ended
Date WC Began
Date WC Ended
Signature of Member
Date
Note:
EMPLOYER VERIFICATION OF WORKERS’ COMPENSATION
(Only periods of Workers’ Compensation after June 12, 1987, are eligible to claim pursuant to AS 39.35.330(c).)
This is to certify that this employee was unable to work due to: 1) an on-the-job injury; or 2) an occupational illness; and 3) received
benefits under AS 23.30. The following information correctly reflect this member’s particular circumstance:
PERIODS OF WORKERS’ COMPENSATION: (use different lines to separate Workers’ Compensation between calendar years)
1.
to
Date WC Began
Date WC Ended
Hourly Rate
Sched Hours
Hours on Workers'
of Pay
per Week
Compensation
2.
to
Date WC Began
Date WC Ended
Hourly Rate
Sched Hours
Hours on Workers'
of Pay
per Week
Compensation
Signature of Employer Representative
Date
Printed Name of Employer Representative
Phone Number
Note: Use reverse side if more than 2 segments are claimed. Examples of verification of Workers’ Compensation are provided for on
page 3.
PERS008 (Rev. 9/16)
G:/publications/forms/pers/pers008.indd
FOR OFFICE USE ONLY
Division of Retirement and Benefits
Juneau: (907) 465-4460
Toll-Free: (800) 821-2251
P.O. Box 110203
TDD: (907) 465-2805
alaska.gov/drb
Juneau, AK 99811-0203
Fax: (907) 465-3086
Member's Name _____________________________________
Social Security Number ________________________________
to
1.
Date WC Began
Date WC Ended
Hourly Rate
Sched Hours
Hours on Workers'
of Pay
per Week
Compensation
to
2.
Date WC Began
Date WC Ended
Hourly Rate
Sched Hours
Hours on Workers'
of Pay
per Week
Compensation
to
3.
Date WC Began
Date WC Ended
Hourly Rate
Sched Hours
Hours on Workers'
of Pay
per Week
Compensation
to
4.
Date WC Began
Date WC Ended
Hourly Rate
Sched Hours
Hours on Workers'
of Pay
per Week
Compensation
to
5.
Date WC Began
Date WC Ended
Hourly Rate
Sched Hours
Hours on Workers'
of Pay
per Week
Compensation
to
6.
Date WC Began
Date WC Ended
Hourly Rate
Sched Hours
Hours on Workers'
of Pay
per Week
Compensation
to
7.
Date WC Began
Date WC Ended
Hourly Rate
Sched Hours
Hours on Workers'
of Pay
per Week
Compensation
to
8.
Date WC Began
Date WC Ended
Hourly Rate
Sched Hours
Hours on Workers'
of Pay
per Week
Compensation
to
9.
Date WC Began
Date WC Ended
Hourly Rate
Sched Hours
Hours on Workers'
of Pay
per Week
Compensation
to
10.
Date WC Began
Date WC Ended
Hourly Rate
Sched Hours
Hours on Workers'
of Pay
per Week
Compensation
Signature of Employer Representative
Date
Printed Name of Employer Representative
Phone Number
PERS008 (Rev. 9/16)
G:/publications/orms/pers/pers008.indd
Example Page
FOR OFFICE USE ONLY
Example one is a period of Workers’ Compensation overlapping into the next year, example two is when there is a salary rate change
during a period of Workers’ Compensation.
to
Division of Retirement and Benefits
Juneau: (907) 465-4460
11/1/2001
12/31/2001
$23.50
40
328
1.
Toll-Free: (800) 821-2251
P.O. Box 110203
TDD: (907) 465-2805
Date WC Began
Date WC Ended
Hourly Rate
Sched Hours
Hours on Workers'
alaska.gov/drb
Juneau, AK 99811-0203
Fax: (907) 465-3086
of Pay
per Week
Compensation
to
1/01/2002
1/14/2002
$23.50
40
72
2.
Date WC Began
Date WC Ended
Hourly Rate
Sched Hours
Hours on Workers'
of Pay
per Week
Compensation
to
4/11/2005
4/29/2005
$27.83
37.5
112.5
3.
Date WC Began
Date WC Ended
Hourly Rate
Sched Hours
Hours on Workers'
of Pay
per Week
Compensation
to
5/1/2005
5/15/2005
$30.26
37.5
75
4.
Date WC Began
Date WC Ended
Hourly Rate
Sched Hours
Hours on Workers'
of Pay
per Week
Compensation
PERS008 (Rev. 9/16)
G:/publications/orms/pers/pers008.indd
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