Workers’ Compensation Employee Form Workers’ Compensation Employee Form Employee Name(Required) First Middle Last Suffix Mailing Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneDate of Birth(Required) MM slash DD slash YYYY Date of Death MM slash DD slash YYYY Social Security or Passport Number(Required) Gender Code Male Female Other Marital Status Married Unmarried Separated Unknown Number of Dependents Claimed on Taxes12345678910Date of Injury / Illness(Required) MM slash DD slash YYYY Time of Injury / Illness Hours : Minutes AM PM AM/PM Did the Injury occur on Employer's Premises? Yes No Explain where the Injury / Illness Occurred Employer Name(Required) Describe Type of Injury / Illness (sprain, strain, laceration, etc.)(Required) Describe Body Part Affected(Required) Body Part Side Left Right Bilateral Describe how the Injury / Illness HappenedWitness Name First Last Witness PhoneAttending Physician Name for this Injury Attending Physician PhoneHospital / Clinic Name for this Injury Hospital / Clinic PhoneInitial Treatment(Required) No Medical Treatment Minor On-site Remedies by Employer Medical Staff Minor Clinic/Hospital Remedies and Diagnostic Testing Emergency Evaluation, Diagnostic Testing, and Medical Procedures Hospitalization Greater than 24 Hours Future Major Medical / Lost Time Anticipated Employee Authorization to Release Medical Records(Required) I agreeYou are authorized to provide my employer (named above), its workers’ compensation liability insurance company, and its claims adjuster information concerning any health care advice, testing, treatment, or supplies provided to me for the injury or illness described above. This information will be used to evaluate my entitlement to receive benefits, including payment of medical benefits, under the Alaska Workers’ Compensation Act. This authorization is valid for a one-year period from the date of my signature (below). I know I have a right to receive a copy of this authorization and agree a photographic copy of this authorization is as valid as the original.Electronic Submission(Required) I agreeI agree and understand that by signing the Electronic Signature and submitting below that it will be considered the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this signature. I further agree my signature on this document is as valid as if I signed the document in writing.Electronic Signature(Required) Δ
