The community of Port Lions Alaska

Workers’ Compensation Employee Form

Workers' Compensation Employee Form

Employee Name(Required)
Mailing Address(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
Gender Code
Marital Status
MM slash DD slash YYYY
Time of Injury / Illness
Did the Injury occur on Employer's Premises?
Body Part Side
Witness Name
Initial Treatment(Required)
Employee Authorization to Release Medical Records(Required)
Electronic Submission(Required)