ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Division of Workers' Compensation P.O. Box 115512, Juneau AK 99811-5512	EMPLOYER REPORT OF OCCUPATIONAL INJURY OR ILLNESS TO DIVISION OF WORKERS’ COMPENSATION
EMPLOYER: All questions with an asterisk (*) must be completed

1. Employer Name*	2. Industry (NAICS) Code Required on New Claims* See http://www.census.gov/cgi-bin/sssd/naics/naicsrch

3. Employer Contact Name & Telephone	4. FEIN*	5. UI Number
920038816
6. Employer Mailing Address*	7. Employer Physical Address
155 S Seward St
City	State	Zip Code	City	State	Zip Code
Juneau	AK	99801
Country, if outside the United States	Country, if outside the United States
8. Employee Name, Last	First	Middle	Suffix
9. Employee Mailing Address*	10. Date of Birth*	11. Date of Death
12. Employee ID Type & Number*
City	State	Zip Code
Country, if outside the United States
Blocks 13 – 20 are to be completed by the Insurer / Claims Administrator submitting this report to the Division of Workers’ Compensation
13. MTC Report*	14. JCN / AWCB*	15. Claim Status*	16. Claim Type*	17. Late Reason Code
18. Full Denial Reason Code	19. Full Denial Effective Date
20. Denial Reason Narrative
21. Policy Information Number	Effective Date	4/1/2016	Expiration Date	4/1/2017
22. Insurer Name	23. Insurer FEIN	24. Insurer Type Code*
City and Borough of Juneau, AK	920038816
25. Claim Administrator Name*	26. Claim Administrator Primary Address*
Northern Adjusters, Inc.	1401 Rudakof Circle
27. Claim Admin FEIN*	28. Claim Admin Claim No.*
92-0036847	(907) 868-3999	City	State	Zip Code
29. Claim Admin Physical/Alternate Postal Code*	99508	Anchorage	AK	99508
30. Insured Name	31. Insured FEIN	32. Insured Type Code*
City and Borough of Juneau, AK	920038816
33. Employment Status*	34. Days Worked / Week	35. Wage	36. Wage Period Code	37. Employee Hire Date
38. Occupation / Job Title*
39. Full Wages Paid for Date of Injury Indicator	40. Employer Paid Salary in Lieu of Compensation Indicator
Employer must complete either Block 41 or 42 AND Block 43:	44. Date of Injury / Illness*	45. Time of Injury / Illness
41. Accident Site Information, if not on Employer Premises
Organization Name	46. Date Employer First Knew of Injury / Illness	47. Date Claim Admin Knew of Injury / Illness
Street
For Blocks 48, 49 & 50 see: https://www.wcio.org/Document%20Library/InjuryDescriptionTablePage.aspx
City	State	Zip Code
Country, if outside the United States	48. Part(s) of Body Affected*	49. Nature of Injury / Illness*
42. Explain Where Injury Occurred
50. Cause of Injury / Illness*	51. Death Result of Injury Code
43. Accident Premises Code*
52. Initial Last Day Worked	53. Initial Date Disability Began	54. Initial Return to Work Date	55. Return to Work Type Code*
56. Return to Work With Same Employer?	57. Physical Restrictions Indicator
58. Signature of Authorized Employer or Representative*	59. Title	60. Date Signed

Instructions for
EMPLOYER REPORT OF OCCUPATIONAL INJURY OR ILLNESS TO ALASKA DIVISION OF WORKERS’ COMPENSATION

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 been 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 Administrator (Adjuster).

The form should be submitted electronically via electronic 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 to the Division of Workers’ 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 Standards 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 injuries.

Monday-Friday Alaska OSH (800) 770-4940 · 24-hour OSHA Hotline (800) 321-6742

“Injury” 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.

“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 experienced 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 evaluation, 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 Anchorage, AK 99503-4149 (907) 269-4980	3301 Eagle Street, #305 Anchorage, AK 99503-4149 (907) 269-4940 or (800) 770-4940
Fairbanks:	675 Seventh Avenue, Station K Fairbanks, AK 99701-4531 (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