Workers’ compensation insurance provides medical and lost wage benefits to workers who are injured on the job. Box 107019 Anchorage, AK 99510-7019 (907) 269-4980 Alaska Workers' Compensation Board 675 Seventh Avenue, Station H2 Fairbanks, AK 99701-4593 (907) 451-2889 Injury Forms. Box 115512 Juneau, AK 99811-5512 AWCB Case Number: WORKERS' COMPENSATION CLAIM 1. Authorization for Examination and/or Treatment. The PDF version cannot be saved to your computer once filled. Mailing Address: PO Box 110201 Juneau, AK 99811. Workers Compensation; Labor Market Information; Labor Relations; Industrial Safety & Health; Amusement Ride; Workplace Laws ; Overpayments; Español; Menu. These should evaluate employees based on the metrics, measures, and SMART goals initiated on 12/20/19 and worked on throughout this last year. Office Locations & Contacts; Forms & Documents; Frequently Asked Questions; Find a job now! State Office Building 333 Willoughby Ave., Juneau, AK. Phone: (907) 465-4430 Fax: (907) 465-3415 Fax (671) 475-6811. Independent Contract Forms. State of Alaska Department of Administration Division of Personnel and Labor Relations. SECTION 1. Application for Approval of Workers' Comp Self-Insurance Program Form RI SI-2; Self-Insured Renewal Application Form RI SI-2a ; Bond of Employer Authorized to pay Workers' Compensation benefits Directly to Employees or their Dependents Form RI SI 5 Initial. File: Form 29 – Application for Exclusion from Provisions of the Workers’ Comp Act –rev 2-13.pdf. The lists are broken down into numbered and alphabetical lists. In March, Washington state’s Department of Labor and Industries announced that health care workers and first responders will receive wage-replacement benefits and have all related health care expenses covered under the state’s workers’ compensation program when quarantined by a physician. However, accidents and illnesses can arise from work and when they do, the employees are covered under the WC law. NCCI stands for The National Council on Compensation Insurance.. See the applicable list below. Box 9970 Tamuning, Guam 96931. Need to find Alaska workers compensation class codes?Alaska uses the NCCI classification system. Alaska Work Comp Class Codes. This form is used by the insurer to voluntarily admit responsibility for payment of workers' compensation benefits where a fatality has occurred. Workers' Comp Forms. The Hawaii WC law was enacted in 1915, and … Spanish versions are available where applicable. Phone: (907) 465-4430 Fax: (907) 465-3415 … Department Directory Employee's Name (Last, First, Middle Initial) 4. City/Town/Village Where Injury Occurred 7. Middle. State of Alaska Department of Administration Division of Personnel and Labor Relations. Friday, May 24, 2019. Employee Responsibilities; Guide to Benefits. * Note: If you want to save this form to your computer and email it to the DWC Medical Unit, you MUST use the Word version. State Office Building 333 Willoughby Ave., Juneau, AK. Address City State Zip Code Telephone 2. Please contact the Department by phone. Unless otherwise noted, the forms are provided in Adobe PDF format. U.S. Department of Labor Office of Workers' Compensation Programs. WC9433r (03-18) Wolters Kluwer Financial Services | Uniform FormsTM ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Division of Workers' Compensation P.O. If you have a classification question or believe you have been incorrectly classified, please see The Employer’s Workers Compensation Classification Guide. CA-16. The DIA uses forms for many reasons. The Office of Workers' Compensation Programs administers four major disability compensation programs which provide wage replacement benefits, medical treatment, vocational rehabilitation and other benefits to certain workers or their dependents who experience work … Excluding 15,190 federal employees, the number of workers covered under the Alaska Workers’ Compensation Act in 2016 was approximately 311,091 compared to 316,757 in … ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Alaska Workers' Compensation Division P.O. Call (307) 777-5476 or email [email protected] Application for those seeking summer work experience in St. Thomas/St. All businesses with employees operating in Colorado are required to have workers’ compensation insurance, regardless of the number of employees, whether the employees only work part-time, or if they are members of the same family. Workers' Compensation Statute : Word: PDF: 6/13/13: Workers' Compensation Rules : Word. This form is only … Electronic Data Interchange (EDI): This will provide important announcements regarding Michigan’s reporting requirements. First Report of Occupational Injury or Disease - The employer must complete and file with their workers' compensation insurance carrier a first report of injury within 10 days of notice of a work accident resulting in personal injury. The Division of Workers' Compensation (DWC) has provided a Form Developer Kit for stakeholders who develop their own forms. Workers' Compensation Forms. Affidavit of Indigency: LB-1108 LB-1108s: Declaración Jurada sobre Indigencia: Claims. Deadline to apply is March 20, 2020. Time Analysis Form, used for claiming compensation, including repurchase of paid leave. It is an important legal document that provides an initial statement of the amount of benefits to be paid in a workers' compensation case. HR Forms & Resources DOA Performance Evaluation Pilot Due Date. Based on Department of Labor & Workforce Development, Research and Analysis Section data of estimated statewide average monthly employment, employment decreased 1.79% from 331,712 in 2015 to 326,281 in 2016. Summer Employment Employer Request Form Providers, please use this form to request students for the Summer Work Experience Program. The spreadsheets provide information relating to available methods of submitting forms to the bureau and the Workers' Compensation Office of Adjudication, forms that … Department of Administration (PDF) (Last Updated: 11/12/20) COVID-19 Return to the Office / Work Site Guidelines (PDF) (Last Updated: 07/29/20) Telecommuting Policy (PDF) Telecommute FAQ; State of Alaska Resources. ; Statewide Average Monthly Wage ; Resources down into numbered and alphabetical lists overview ; Claims Injuries! Word: PDF: 6/13/13: workers ' Compensation benefits where a fatality occurred. 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