Coastal Alaskan community in winter.

Workers’ Compensation Employer Form

Workers' Compensation Employer Form

Employer Contact Name
Employer Mailing Address(Required)
Employee Name(Required)
Employee Address(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
Time of Injury / Illness
:
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
Electronic Submission(Required)
MM slash DD slash YYYY