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]

• Claim for Benefits (Form 07-6106) [PDF]

• 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]

• Employee's Lien for Workers' Compensation Benefits (Form 07-6179) [PDF]
  (Also available in Microsoft Word) [DOCX]

• Report of Occupational Injury or Illness (Form 07-6101)

  This form is provided for convenience, but use of this specific form is not required by the Division of Workers’ Compensation. Many insurers and claims administrators maintain their own forms or reporting procedures. The employer’s reporting obligation is satisfied when the injury is reported to the Division by the insurance carrier or claims administrator through electronic data interchange (EDI).

  State of Alaska employee injuries must be reported through the Division of Risk Management’s Report of Injury Portal.

• 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]

• Reemployment, Employer Notice of 25 Consecutive Days of Time Loss (Form 07-6185)

• Reemployment, Employer Notice of 120 Consecutive Days of Time Loss (Form 07-6186)

• Reemployment, Employer Notice to Opt Out of Stay-at-Work Benefits (Form 07-6187)

• 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)

last updated: March 16, 2026