Report Of Occupational Injury Or Illness {07-6101}

07 - 6101 ( REV 03/ 2018 ) Page 1 of 2 ALASKA D EPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Div ision of Workers' Compensation P.O. Box 115512, Juneau AK 99811 - 5512 EMPLOYE R REPORT OF OCCUPATIONAL INJURY OR ILLNESS TO EMPLOYER: All questions with an asterisk (* ) must be completed 3. Employer Contact Name & Telephone 4. FEIN* 5. UI Number 6 . Employer Mailing Address * 7 . Employer Physical Address City State Zip Code City State Zip Code Country, if outside the Un ited States Country, if outside the United States 8 . Employee Name, Last First Middle Suffix 9 . Employee Mailing Address* 1 0 . Date of Birth* 11 . Date of Death 1 2 . Employee ID Type & Number * City State Zip Code SELECT ONE Country, if outside the United States Blocks 13 20 are to be completed b y the Insurer / Claims Administrator submitting this report to the Di 13. MTC Report* 14. JCN / AWCB* 15. Claim Sta tus* 16. Claim Type* 17. Late Reason Code SELECT ONE SELECT ONE SELECT ONE DROP DOWN LIST 18 . Full Denial Reason Code 19 . Full Denial Effective Date DROP DOWN LIST DROP DOWN LIST DROP DOWN LIST DROP DOWN LIST DROP DOWN LIST 20 . Denial Reason Narrative 21 . Policy Information Number Effective Date Expiration Date 22 . Insurer Name 23 . Insurer FEIN 24 . Insurer Type Code* SELECT ONE 25 . Claim Administrator Name* 26 . Claim Administrator Primary Address* 27 . Claim Admin FEIN* 28 . Claim Admin Claim No.* City State Zip Code 29 . Claim Admin Physical/Alternate Postal Code* 30 . Insured Name 31 . Insured FEIN 32 . Insured Type Code* SELECT ONE 33 . Employment Status* 34 . Days Worked / Week 35 . Wage 36 . Wage Period Code 37 . Employee Hire Date SELECT ONE DROP DOWN LIST 38 . Occupation / Job Title 39 . Full Wages Paid for Date of Injury Indicator DROP DOWN 40 . Employer Paid Salary in Lieu of Compensation Indicator SELECT ONE Employ er must c omplete either Block 41 or 42 AND Block 43 : 4 4 . Date of Injury / Illness* 4 5 . Time of Injury / Illness 41 . Accident Site Information, if not on Employer Premises Organization Name 4 6 . Date Employer First Knew of Injury / Illness 4 7 . Date Claim Admin Knew of Injury / Illness Street For Blocks 48, 49 & 50 see: https://www.wcio.org/Document%20Library/InjuryDescriptionTablePag e.aspx City State Zip Code Country, if outside the United States 4 8 . Part(s) of Body Af fected* 4 9 . Nature of Injury / Illness* 42 . Explain Where Injury Occurred 50 . Cause of Injury / Illness* 51 . Death Result of Injury Code 43 . Accident Premises Code* SELECT ONE DROP DOWN LIST 5 2 . Initial Last Day Worked 5 3 . Initial Date Disability Began 54 . Initial Return to Work Date 55 . Return to Work Type Code* DROP DOWN LIST 56 . Return to Work Wit h Same Employer? DROP DOWN 57 . Physical Restrictions Indicator DROP DOWN LIST 58 . Signature of Authorized Employer or Representative 59 . Title 60 . Date Signed 1. Employer Name* 2. Industry (NAICS) Code Required on New Claims* See http://www.census.gov/cgi - bin/sssd/naics/naicsrch American LegalNet, Inc. www.FormsWorkFlow.com 07 - 6101 ( REV 03/ 2018 ) Page 2 of 2 Instructions for EMPLOYER REPORT OF OC CUPATIONAL INJURY OR ILLNESS TO ALASKA DIVISION OF Employer: This form must be completed and sent immediately, and in no case later than ten (10) days after you have knowledge that your employee has been injured, or claims to have be en injured or become ill while working for you . You have the option of completing this form electronically or by hand prior to sending the completed to your Insurer/Claims Administra tor (Adjuster). The form should be submitted electronically via electr onic data interchange (EDI). If you or your insurer is not registered and approved to submit reports electronically, mail this form (07 - 6101) and form 07 - 6100 Compensation, P.O. Box 115512, Juneau, AK 99811 - 5512. Make sure and keep a copy for your records. Failure to file this report within the required time may subject you and/or your insurer to a penalty equal to 20 percent of the amount of compensation due to the injured worker. AS 23.30.070 INFORMATION IN FILES MAINTAINED BY THE DIVISION OF WORKERS' COMPENSATION, EXCEPT FOR MEDICAL AND REHABILITATION RECORDS , IS AVAILABLE FOR PUBLIC REVIEW AND COPYING FOR NONCOMMERCIAL PURPOSES. AS 23.30.107 OSHA REQUIREMENTS Report industrial deaths and accidents to the Division of Labor S tandards and Safety. Alaska Statute 18.60.058 requires employers to report to Division of Labor Standards and Safety any employment accident which is fatal to one or more employees or which results in the overnight hospitalization of one or more employees. The report, which must be made immediately, but no later than 8 hours after receipt by the employer of information that the accident has occurred, must relate the circumstances of the accident, the number of fatalities, and the extent of the injurie s. Mon day - Friday Alaska OSH (800) 770 - 4940 267 24 - hour OSHA Hotline (800) 321 - 6742 means accidental injury or death arising out of in the course of employment and an occupational disease, illness, or infection which arises naturally out of the employment or which naturally or unavoidably results from an accidental injury. does not include mental injury caused by stress unless it is established that (A) the work stress was extraordinary and unusual in comparison to pressures and tensions experience d by individuals in a comparable work environment, and (B) the work stress was the predominant cause of the mental injury. A mental injury is not considered to arise out of and in the course of employment if it results from a disciplinary action, work eval uation, job transfer, layoff, demotion, termination, or similar action taken in good faith by the employer. Alaska Division of Worker's Compensation Offices: Alaska Division of Labor Standards and Safety Offices: Anchorage: 3301 Eagle Street, #304 Anchor age, AK 99503 - 4149 (907) 269 - 4980 1251 Muldoon Road, Suite 109 Anchorage, AK 99504 (907) 269 - 4940 or (800) 770 - 4940 Fairbanks: 675 Seventh Avenue, Station K Fairbanks, AK 99701 - 45 31 (907) 451 - 2889 Juneau: 1111 West 8th Street, #305 PO Box 115512 Juneau, AK 99811 - 5512 (907) 465 - 2790 1111 West 8th Street, #304 PO Box 111149 Juneau, AK 99811 - 1149 (907) 465 - 4855 American LegalNet, Inc. www.FormsWorkFlow.com