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)
Affidavit of Complete SIME Records (Form 07-6148)
Affidavit of Readiness for Hearing (Form 07-6107)
Annual Report Record Layout (Form 07-6115)
(Microsoft Excel format)
Change of Address (Form 07-6138)
(Also available in Microsoft Word)
Claim for Benefits (Form 07-6106)
Compensation Report (Form 07-6104b)
Compensation Report - Legacy Claims (Form 07-6104b - Legacy Claims)
Compromise and Release Agreement Summary (Form 07-6117)
Controversion (Denial) Notice (Form 07-6105)
Death Benefits Report (Form 07-6118)
EDI, Instructions for Use of Claims R3 Forms (Form 07-61XX)
EDI Crosswalk, Compensation Report (Form 07-6104b)
EDI Crosswalk, Employee Report of Occupational Injury or Illness to Employer (Form 07-6100)
EDI Crosswalk, Employer Report of Occupational Injury or Illness to Division of Workers’ Compensation (Form 07-6101) [updated 08/2015]
Employee Report of Occupational Injury or Illness to Employer, Effective 07/22/2013 (Form 07-6100)
Employer Report of Occupational Injury or Illness to Division of Workers’ Compensation (Form 07-6101) [updated 03/2015]
Employers' Notice of Insurance (Form 07-6120)
Firefighter’s Lung & Heart Physical Examination and Cancer Screening (Form 07-6177)
Firefighter’s Medical History & Evaluation (Form 07-6176)
Fishermen’s Fund, Claim Form (Form 07-6125)
Fishermen’s Fund, Compelling Reasons Questionnaire (Form 07-6124)
(Also available in Microsoft Word)
Fishermen’s Fund, Medical and Related Transportation or Other Expenses
Fishermen’s Fund, Physician's Report (Form 07-6126)
Fishermen’s Fund, Report of Vessel/Site Insurance (Form 07-6119)
(Also available in Microsoft Word)
Fisherman's Fund, Request for Release of Information (Form 07-6133)
Fishermen’s Fund, Vessel Owner (Employer) – Crewman Agreement
Medical Summary (Form 07-6103)
Notice of Appearance (Form 07-6116)
Notice of Intent to Rely (Form 07-6114)
Petition (Form 07-6111)
Physician's Report (Form 07-6102)
Public Records Request (Form 07-6122)
Reemployment, Application to Provide Reemployment Services as a Rehabilitation Specialist Under AS 23.30.041 (Form 07-6166)
Reemployment, Eligibility Evaluation Checklist (Form 07-6150)
(Also available in Microsoft Word)
Reemployment, Employer Notice of 45 Consecutive Days of Time Loss for Injuries
(Form 07-6170)
Reemployment, Employer Notice of 90 Consecutive Days of Time Loss for Injuries
(Form 07-6169)
Reemployment, Guide for Preparing Reemployment Benefits Eligibility Evaluations
(Form 07-6161)
Reemployment, Offer of Alternative Employment (Form 07-6151)
(Also available in Microsoft Word)
Reemployment, Reemployment Benefits Plan Checklist (Form 07-6171)
Reemployment, Stipulation to Eligibility for Injuries (Form 07-6152)
Reemployment, Waiver of Reemployment Benefits (Form 07-6168)
(Also available in Microsoft Word)
Release of Medical Information (Form 07-6146) (Rev. 05/13/2011)
Request for Conference (Form 07-6135)
(Also available in Microsoft Word)
Request for Cross-examination (Form 07-6174)
Request for Release of Information (Form 07-6121)
(Also available in Microsoft Word)
Second Independent Medical Evaluation (SIME) (Form 07-6147)
Self-Insurance, Application for Certificate of Self-Insurance (Form 07-6129)
(Also available in Microsoft Word)
Self-Insurance, Parent Company Guarantee
Self-Insurance, Renewal of Certificate of Self-Insurance (Form 07-6130)
(Also available in Microsoft Word)
Special Investigations Brochure (Form WCD-005)
Subpoena (Form 07-6112)