Form 07-6106 - Workers' Compensation Claim
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1
2ALASKA DEPARTMENT OF LABOR
AWCB Case Number:
& WORKFORCE DEVELOPMENT
Alaska Workers’ Compensation Division
P.O. Box 115512
Juneau, AK 99811-5512
WORKERS’ COMPENSATION CLAIM
1. Employee’s Name (Last, First, Middle Initial)
2. Insurer Claim Number
3. Injury Date
4. Address
5. City/Town/Village Where Injury Occurred
6. Social Security Number
City
State
Zip Code
Telephone
7. Occupation
8. Date of Birth
9. Employer at Time of Injury
10. Insurer/Adjusting Company
11. Address
12. Address
City
State
Zip Code
Telephone
City
State
Zip Code
Telephone
13. Describe how the injury or illness happened:
14. Part of Body Injured
Right
Left
15. Nature of injury or illness:
16. Full name and address of attending physician(s):
17. Reason for filing claim (be specific):
18. This claim amends a prior claim dated
CONTINUED ON BACK
07-6106 (Revised 5/06)
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