Alaska Workers' Compensation Claim Letter When Agency Form Is Unavailable
ALASKA WORKERS' COMPENSATION CLAIM LETTER WHEN AGENCY FORM IS UNAVAILABLE
Use this letter if you cannot obtain the Division's current Claim for Benefits, Form 07-6106, in time. The Division's claimant guide directs a person in that situation to write the claim details in a signed letter to the Board, employer, and insurer. Confirm the filing address and method with the Division. Check the applicable claim and hearing deadlines promptly; this letter does not request a hearing.
Date: [__/__/____]
To: Alaska Workers' Compensation Board, Division of Workers' Compensation
P.O. Box 115512, Juneau, AK 99811-5512
From: [CLAIMANT FULL NAME]
Mailing address: [STREET, CITY, STATE, ZIP]
Telephone: [PHONE] Email: [EMAIL]
Employee, if different from claimant: [FULL NAME AND ADDRESS]
Employer at time of injury: [NAME AND ADDRESS]
Insurer or claims administrator, if known: [NAME AND ADDRESS]
Board case number, if known: [NUMBER] Insurer claim number, if known: [NUMBER]
Re: Written claim for workers' compensation benefits; injury date [__/__/____]
I submit this written claim for workers' compensation benefits arising from the injury or illness described below. The benefits identified here have not been paid or remain disputed. Please file this claim and send me notice of the case number and any information needed to process it.
Date, location, and work activity when the injury or illness occurred: [DETAILS]
How the injury or illness occurred and affected body parts or condition: [DETAILS]
Date and manner of notice to employer: [DETAILS]
Injury report status: ☐ Employer reported the injury to the Division ☐ I do not know whether it was reported ☐ Employer has refused or is unavailable to report it; I will contact the Division
Benefits requested and period or amount, if known: [IDENTIFY EACH DISABILITY, MEDICAL, TRANSPORTATION, IMPAIRMENT, DEATH, OR OTHER BENEFIT SOUGHT]
What the employer or insurer has paid or denied, and when: [DETAILS]
Why the remaining benefits are due: [FACTS AND SUPPORTING RECORDS]
Documents enclosed: [LIST; INCLUDE ANY DENIAL, WAGE RECORDS, MEDICAL SUMMARY, OR OTHER MATERIAL BEING SUBMITTED]
Please send correspondence to the address above. I will update the Division and other parties if my contact information changes.
Claimant or authorized representative signature: [SIGNATURE] Date: [__/__/____]
Printed name and capacity, if signing for the employee: [NAME AND CAPACITY]
Copies sent to: Employer [NAME / ADDRESS / DATE / METHOD]; insurer or administrator [NAME / ADDRESS / DATE / METHOD]
Official sources
About this template
- Last updated
- October 27, 2026
- Citations checked
- October 27, 2026
- Jurisdiction
- Alaska
- Category
- Employment & HR
Legal authority
- AS 23.30.110(a) (claim filed with the Board subject to AS 23.30.105 and Board regulations)
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 October 27, 2026.
AS 23.30.110(a) (checked October 27, 2026): "a claim for compensation may be filed with the board in accordance with its regulations"
Alaska Division of Workers' Compensation, Workers' Compensation and You, p. 19 (checked October 27, 2026): "IF YOU CANNOT OBTAIN FORMS, WRITE THE DETAILS OF YOUR CLAIM IN A LETTER TO THE BOARD, EMPLOYER AND INSURER."
Alaska Division of Workers' Compensation, Claim for Workers' Compensation Benefits, Form 07-6106 (checked October 27, 2026): "This Claim form is used to request benefits an employer has not paid and to which you believe you are entitled."
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