Compensation Report {07-6104b}

ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Division of Workers' Compensation P.O. Box 115512 Juneau, AK 99811-5512 COMPENSATION REPORT First* 3. Date of Birth* State Zip Code MTC Report No.* SELECT ONE Middle JCN / AWCB No:* EMPLOYEE: 1. Employee's Name, Last* 2. Employee Mailing Address* City Suffix 4. Date of Death Country, if outside the United States 8. Number of Entitled Exemptions 5. Employee ID Type & Number* SELECT ONE 6. Number of Dependents 7. Marital Status* SELECT ONE 9. Employee Tax Filing Status Code DROP DOWN LIST EMPLOYER: 10. Employer Name 11. Employer FEIN* 12. Employer Mailing Address City State Zip Code CLAIM ADMINISTRATOR: 14. Claim Administrator Name* 15. Claim Administrator FEIN* 16. Claim Administrator Mailing Address City State Zip Code* 13. Employer Contact Name & Telephone Number 17. Claim Administrator Claim Number* 18. Claim Admin Alternate / Physical Postal Code* INSURED: 19. Insured Name 21. Insured FEIN 22. Insurer FEIN* INSURER: 20. Insurer Name 23. Insolvent Insurer FEIN CLAIM STATUS: 24. Claim Status* 25. Claim Type* 26. Late Reason Code 27. Lump Sum Payment / Settlement Code SELECT ONE SELECT ONE DROP DOWN LIST DROP DOWN LIST 28. Award Order Date 29. Partial Denial Code 30. Suspension Eff. Date* 31. Suspension Narrative* DROP DOWN LIST 32. Full Denial Reason Code 33. Full Denial Eff. Date 34. Denial Rescission Date 35. Denial Reason Narrative DROP DOWN LIST DROP DOWN LIST DROP DOWN LIST DROP DOWN LIST DROP DOWN LIST BENEFIT TYPE(S): 36. Reduced Benefit Amount Code DROP DOWN LIST 40. Benefit Type Payment(s) 37. Non-Consecutive Period Code DROP DOWN LIST 38. Estimated Gross Weekly Amount Indicator DROP DOWN LIST Benefit Period Weeks Days Start Date 39. Calculated Weekly Compensation (Up to 10) Payment Date Amount (Up To 90) Amount Amount Amount (Up to 25) Amount Page 1 of 3 Gross Weekly Net Weekly SEQ BTC* MTC Eff. Date Amount Eff. Date Amount 01 BTC LISTMTC LIST 02 BTC LISTMTC LIST 41. Benefit Adjustment(s) / Credit(s) / Redistribution(s) A. Benefit Adjustment(s) SEQ Code 01 DROP DOWN LIST B. Benefit Credit(s) SEQ Code 01 DROP DOWN LIST C. Benefit Redistribution(s) SEQ Code 01 DROP DOWN LIST Thru Date Start Date Start Date Start Date End Date End Date End Date OTHER BENEFIT TYPE(S): 42. Other Benefit Type(s) Payment(s) 07-6104b (REV 12/2015) SEQ 01 OBT Code 3xx OBT LIST 4xx OBT LIST American LegalNet, Inc. www.FormsWorkFlow.com ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Division of Workers' Compensation P.O. Box 115512 Juneau, AK 99811-5512 COMPENSATION REPORT First* MTC Report No.* SELECT ONE Middle JCN / AWCB No:* EMPLOYEE: 1. Employee's Name, Last* Suffix PAYMENT SUMMARY: 43. Payments Pymt Reason SEQ Code* 01 xxx BTC LIST 3xx OBT LIST 4xx OBT LIST (Up to 5) Period Start Date* Thru Date* Payment(s) Issue Date* Amount* Payee Name* RECOVERIES: 44. Recoveries SEQ 01 SEQ 01 Recovery Code DROP DOWN LIST Week No.* PPE Date Actual* (Up to 25) Amount (Up to 52) Deemed REDUCED EARNINGS: 45. Reduced Earnings EMPLOYMENT: 46. Employment Status* 47. Days Worked / Week 48. Wage Effective Date 49. Average Wage 50. Wage Period Code SELECT ONE DROP DOWN LIST 51. Full Wages Paid for Date of Injury Indicator DROPDOWN 52. Employer Paid Salary in Lieu of Compensation Indicator DROPDOWN INJURY: 53. Injury Date* 54. Date of Medical Stability 57. Loss Type SELECT ONE 59. Permanent Impairment Body Part & Percentage (up to 6) 55. Pre-Existing Disability* 56. Death Result of Injury SELECT ONE DROP DOWN LIST 58. Permanent Impairment Minimum Payment Indicator DROP DOWN LIST % % % % % % 62. Initial Date Last Day Worked 63. Initial Date Disability Began 64. Initial Date Return to Work DISABILITY: 60. Initial Date Claim Admin Knew of Lost Time 65. Current Date Last Day Worked 68. Return to Work Type Code DROP DOWN LIST 61. Initial Date of Lost Time 66. Current Date Disability Began 69. Physical Restrictions Indicator DROP DOWN LIST SEQ 01 Relationship Birth Order DROP DOWN LISTDROP DOWN LIST 67. Current Date Return to Work 70. Return to Work With Same Employer? DROP DOWN LIST Name (Up to 12) DEPENDENT RELATIONSHIP: 71. Dependent Relationship Code CONCURRENT EMPLOYER: 72. Concurrent Employer 1 73. Concurrent Employer 2 SROI LEGACY CLAIMS: I certify I have mailed the original Compensation Report to the employee at the address above and a copy to the Alaska Division of Workers' Compensation. 74. Name and Title of Person Submitting Report (Type or Print) 77. Address (if different from No. 17 above) City State Zip Code* Telephone 75. Signature 76. Date 07-6104b (REV 12/2015) American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3 ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Division of Workers' Compensation P.O. Box 115512 Juneau, AK 99811-5512 COMPENSATION REPORT First* MTC Report No.* SELECT ONE Middle JCN / AWCB No:* EMPLOYEE: 1. Employee's Name, Last* 78. ABBREVIATIONS AWCB ­ Alaska Workers' Compensation Board (same as JCN) BTC ­ Benefit Type Code. FEIN ­ Federal Employer Identification Number JCN ­ Jurisdiction Claim Number (same as AWCB Number) MTC ­ Maintenance Type Code OBTC ­ Other Benefit Type Code PPE ­ Pay Period Ending SEQ ­ Sequence Number 79. INSTRUCTIONS A compensation report must be submitted to the Division of Workers' Compensation within 28 days of the first payment of compensation, and when benefits are changed, increased, decreased, suspended, terminated, or resumed. The compensation report should be submitted electronically via electronic data interchange (EDI). If you and/or your insurer is/are not registered and approved to submit reports electronically, mail the form to the Division of Workers' Compensation, P.O. Box 115512, Juneau, AK 998115512. Make sure you keep a copy for your records. If a compensation report is not filed within 28 days of the 28 days of the first payment of compensation, or when benefits are changed, increased, decreased, suspended, terminated, or resumed, the employer, insurer, or adjuster may be subject to civil penalties up to $1,000 per late report. DIVISION OF WORKERS' COMPENSATION OFFICE Fairbanks Juneau 675 Seventh Avenue, Station P.O. Box 115512, Juneau AK 99811-5512 Fairbanks, AK 99701 1111 W 8th Street, Room 305, Juneau AK 99801 Telephone: 907-451-2889 Telephone: 907-465-2790 Suffix Anchorage 3301 Eagle Street, Suite 304 Anchorage AK 99503 Telephone: 907-269-4980 07-6104b (REV 12/2015) American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 3