Alaska Employee Notice of Occupational Injury or Illness
ALASKA EMPLOYEE NOTICE OF OCCUPATIONAL INJURY OR ILLNESS
Before you use this: Give written notice to your employer promptly. AS 23.30.100(a) states a 15-day period after injury or death. If an illness was discovered later, obtain advice promptly about the date that applies. The Division's Form 07-6101 is an optional reporting form; your employer or insurer may use another reporting process. Confirm that the format used meets the Division's current requirements. State of Alaska employees should also use the state risk-management reporting portal.
Date of notice: [__/__/____]
To, employer's name: [________________________________]
Employer's business address: [________________________________]
From, employee's full name: [________________________________]
Employee's mailing address: [________________________________]
Employee's phone or email: [________________________________]
Re: Notice of occupational injury or illness
I give notice of an injury or illness that I believe arose from my work for the employer named above.
Date and time of injury or onset: [________________________________]
Place where it happened: [________________________________]
Work activity and how it happened: [________________________________]
Nature of injury or illness and body parts affected: [________________________________]
When I first recognized a possible connection to work, if later: [________________________________]
Witnesses, if any: [________________________________]
Medical treatment received or sought, if any: [________________________________]
For this reported injury or illness, I authorize the release of records of its medical treatment to my employer, its workers' compensation insurer, and its claim administrator for evaluation of this report and any related benefits. This authorization concerns this injury or illness only. A provider may require a separate authorization before releasing records.
Employee signature: [________________________________] Date: [__/__/____]
If someone signs for the employee, name, relationship, and reason: [________________________________]
Signature of person acting for employee: [________________________________] Date: [__/__/____]
Delivery record: ☐ Delivered to employer ☐ Mailed to employer's last known business address
Recipient, delivery or mailing date, and proof kept: [________________________________]
This notice is distinct from a claim for compensation. The employer or its carrier is responsible for its separate report to the Division. Keep a copy and delivery proof. If notice was late or the employer already knew of the injury, AS 23.30.100(d) lists circumstances in which failure to give notice does not bar a claim; seek case-specific review.
Sources
About this template
- Last updated
- November 4, 2026
- Citations checked
- November 4, 2026
- Jurisdiction
- Alaska
- Category
- Employment & HR
Legal authority
- AS 23.30.100(a)-(d)
- Alaska Division of Workers' Compensation, Report of Occupational Injury or Illness, Form 07-6101 (rev. 03/2026), employee instructions
Employment documents govern the relationship between a company and its workers, from offer letters and employment agreements through handbooks, performance reviews, and separations. Done right, they set clear expectations, protect against wrongful termination and discrimination claims, and give both sides a record to rely on. Done poorly, they invite lawsuits, agency complaints, and costly disputes.
Not legal advice
This template is provided for informational purposes. We recommend having an attorney review any legal document before signing, especially for high-value or complex matters.
Checked against the law it cites
A reviewer verified this template's legal citations against the official source on November 4, 2026.
AS 23.30.100(a) (checked November 4, 2026): "Notice to an employer of an injury or death in respect to which compensation is payable under this chapter shall be given within 15 days after the date of the injury or death."
AS 23.30.100(b) (checked November 4, 2026): "The notice must be in a format prescribed by the director and contain the name and address of the employee, a statement of the time, place, nature, and cause of the injury or death, and authority to release records of medical treatment for the injury or death"
AS 23.30.100(c) (checked November 4, 2026): "Notice shall be given to the employer by delivering it to the employer or by sending it by mail addressed to the employer at the employer's last known place of business."
AS 23.30.100(d) (checked November 4, 2026): "Failure to give notice does not bar a claim under this chapter"
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