Free 07-6135 - Alaska

ALASKA DEPARTMENT OF LABOR Alaska Workers' Compensation Board P.O. Box 25512 Juneau, Alaska 99802-5512

AWCB Case Number

Request for Conference

Use this form to request a prehearing or settlement conference. It may be filed only after a "Workers' Compensation Claim" (Form 07-6106) or "Petition" (Form 07-6111) has been filed. I. Attach a completed "Medical Summary" (Form 07-6103) if you have new medical reports since you filed your last Medical Summary. II. If you want to raise additional issues not listed on your original Claim/Petition, an amended form MUST be attached.
1. Employee's Name (Last, First, Middle Initial) 2. Date of Injury

3. Address

4. Social Security Number

City

State

Zip Code

Telephone

5. Date of Birth

6. Employer

7. Insurer/Adjusting Company

8. Address

9. Address

City

State

Zip Code

Telephone

City

State

Zip Code

Telephone

10. Please schedule a (CHOOSE ONE)

r Prehearing Conference or a

r Settlement Conference in: r Fairbanks 675 7th Avenue, Station H2 Fairbanks, Alaska 99701-4593 Date Controversion Notice filed: r Juneau P.O. Box 25512 Juneau, Alaska 99802-5512

r Anchorage P.O. Box 107019 Anchorage, Alaska 99510-7019 11. Employee's claim was controverted: r Yes r No r No

12. Employee is now receiving compensation payments: r Yes

Weekly Rate $

13. List the dates you will be available for a conference in the next 30 days:

14. Attorney's Name and Firm Name (if represented)

15. Attorney's Address

City

State

Zip Code

Telephone

16. Name of Person Submitting Form (Print or Type)

17. Signature

18. Address

City

State

Zip Code

Telephone

19. PROOF OF SERVICE: I certify that on the date in #22 below I mailed/delivered a true and correct copy of this request to the following (request will be returned with no action if all parties are not served): a. r The employee in #1 above at the address in #3 c. r The insurer in #7 above at the address in #9 Name b. r The employer in #6 above at the address in #8 d. r Other (State name and address): Address

Name

Address

20. Name of person serving request

21. Signautre

22. Date

Form 07-6135 (rev. 11/97)

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