ࡱ> 58234)` bjbj 8.{{JJJJJJJJ6@6@6@8n@lA4sjD.HJ(pJpJpJKVO$Qrrrrrrr$fuhwrJ\KK\\rJJpJpJ4s'a'a'a\JpJJpJr'a\r'a'aJJ'apJD tE6@^('aOjls0s'ax_x'axJ'a( Qx*Uz'aWYEQQQrraQQQs\\\\&6@6@^$JJJJJJ ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Division of Workers' Compensation P.O. Box 115512, Juneau AK 99811-5512 EMPLOYER REPORT OF OCCUPATIONAL INJURY OR ILLNESS TO DIVISION OF WORKERS COMPENSATIONEMPLOYER: All questions with an asterisk (*) must be completed 1. Employer Name*2. Industry (NAICS) Code Required on New Claims* See  HYPERLINK "http://www.census.gov/cgi-bin/sssd/naics/naicsrch" http://www.census.gov/cgi-bin/sssd/naics/naicsrch FORMTEXT        FORMTEXT        3. Employer Contact Name & Telephone4. FEIN*5. UI Number FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       6. Employer Mailing Address*7. Employer Physical Address FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       CityStateZip CodeCityStateZip Code FORMTEXT        FORMTEXT     FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT       Country, if outside the United States FORMTEXT       Country, if outside the United States FORMTEXT     8. Employee Name, LastFirstMiddleSuffix FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT      9. Employee Mailing Address*10. Date of Birth*11. Date of Death  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       12. Employee ID Type & Number* CityStateZip Code FORMDROPDOWN   FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT       Country, if outside the United States  FORMTEXT     Blocks 13  17 are to be completed by the Insurer / Claims Administrator submitting this report to the Division of Workers Compensation13. MTC Report*14. JCN / AWCB*15. Claim Status*16. Claim Type*17. Late Reason Code FORMDROPDOWN   FORMTEXT        FORMDROPDOWN   FORMDROPDOWN   FORMDROPDOWN   FORMDROPDOWN 18. Policy Information Number  FORMTEXT       Effective Date  FORMTEXT       Expiration Date  FORMTEXT       19. Insurer Name20. Insurer FEIN21. Insurer Type Code*  FORMTEXT        FORMTEXT        FORMDROPDOWN  22. Claim Administrator Name*23. Claim Administrator Primary Address* FORMTEXT        FORMTEXT       24. Claim Admin FEIN*25. Claim Admin Claim No.* FORMTEXT        FORMTEXT        FORMTEXT       CityStateZip Code26. Claim Admin Physical/Alternate Postal Code* FORMTEXT        FORMTEXT        FORMTEXT     FORMTEXT       27. Insured Name28. Insured FEIN29. Insured Type Code*  FORMTEXT        FORMTEXT        FORMDROPDOWN  30. Employment Status*31. Days Worked / Week32. Wage33. Wage Period Code34. Employee Hire Date FORMDROPDOWN   FORMTEXT    FORMTEXT        FORMDROPDOWN   FORMTEXT       35. Occupation / Job Title FORMTEXT       36. Full Wages Paid for Date of Injury Indicator FORMDROPDOWN  37. Employer Paid Salary in Lieu of Compensation Indicator FORMDROPDOWN  Employer must complete either Block 38 or 39 AND Block 40:41. Date of Injury / Illness*42. Time of Injury / Illness38. Accident Site Information, if not on Employer Premises FORMTEXT        FORMTEXT       Organization Name43. Date Employer First Knew of Injury / Illness44. Date Claim Admin Knew of Injury / Illness FORMTEXT       Street FORMTEXT        FORMTEXT        FORMTEXT       For Blocks 45, 46 & 47 see:  HYPERLINK "https://www.wcio.org/Document%20Library/InjuryDescriptionTablePage.aspx" https://www.wcio.org/Document%20Library/InjuryDescriptionTablePage.aspxCityStateZip Code FORMTEXT        FORMTEXT     FORMTEXT       Country, if outside the United States  FORMTEXT     45. Part(s) of Body Affected*46. Nature of Injury / Illness*39. Explain Where Injury Occurred FORMTEXT     FORMTEXT     FORMTEXT       47. Cause of Injury / Illness*48. Death Result of Injury Code40. Accident Premises Code* FORMDROPDOWN   FORMTEXT     FORMDROPDOWN  49. Injury / Illness Due to Machine/Product Failure? FORMDROPDOWN 51. Mechanical Guard/Safeguards Provided? FORMDROPDOWN 50. List Any Machine/Substance/Object Causing Injury / Illn}~    . 7 ? ѿяxiaQC5h hG5CJOJQJh hR5CJOJQJh*h15CJOJQJ^Jh*h?<h*h%CJOJQJaJ,h*h%5B*CJOJQJ^JaJph(h*he^5B*CJOJQJ^Jphh*h%aJ"h*h&I5OJQJ\^JaJ"h*h%5OJQJ\^JaJ h*h%&h*h&I5CJOJQJ\^JaJ&h*h%5CJOJQJ\^JaJ4X UI $$Ifa$gde^kd$$IfTl4  0 >+J ` t0  +44 laf4yts)T $$Ifa$gd&I  $Ifgd&I $7$8$H$Ifgd&I<   + z^B $& #$/If^ `b$gdG $& #$/If^ `b$gdVgd?kd$$IfTl4  >++  t 0  +44 laf4p yts)T? C \ ` a    ( * , 6 8 < @ B нннЖ}pZ}Ip h*h1CJOJQJ^JaJ+jsh*h1CJOJQJU^Jh*h1CJOJQJ0jh*h1CJOJQJU^JmHnHu+jh*h1CJOJQJU^J h*h10JCJOJQJ^J%jh*h1CJOJQJU^Jh*h1CJOJQJ^Jh*h15CJOJQJ^Jh h15CJOJQJ^J   &kd$$Ifl4  F2'>+8  t 6 0  +    44 lae4f4pyt9J $& #$/If^ `b$gd1 < > @  $& #$/If^ b$gdV $& #$/If^ b$gd1@ B D QL;;; $If^ `gd1gd?kd$$Ifl4  F2'>+8 t 6 0  +    44 lae4f4pyt9JB D   & ( * 4 6 : < P R T ^ ` f h ůԖŀԖjԖTԖ+jh*hGdCJOJQJU^J+jh*hGdCJOJQJU^J+jh*hGdCJOJQJU^J0jh*hGdCJOJQJU^JmHnHu+jh*hGdCJOJQJU^Jh*hGdCJOJQJ^J%jh*hGdCJOJQJU^Jh*hV5CJOJQJ^Jh*h?<  : d C6-66 $Ifgd1  $If^ gd1kdO$$IfTl4  F#>+Y^  t0  +     44 laf4pytETd f @// $If^ `gd1kd$$IfTl4  \.#>+YY^ t0  + 44 laf4p(ytETh j l ~   q[Bq0jh*h^CJOJQJU^JmHnHu+j h*ha`CJOJQJU^Jh*ha`CJOJQJ^J%jh*ha`CJOJQJU^Jh*ht^CJOJQJh*ht^CJOJQJ^Jh*hV5CJOJQJ^Jh*hx#5CJOJQJ^Jh*h='5CJOJQJ^Jh*hN5CJOJQJ^Jh*ht^5CJOJQJ^J  0 aTG $If^gd1  $If^ gd1kd $$IfTl4  0.>+  t0  + 44 laf4pytET    * , 0 2 4 H J L V X Z \ ^ 쟒pZAp.%jh*ha`CJOJQJU^J0jh*h^CJOJQJU^JmHnHu+j h*ha`CJOJQJU^Jh*ha`CJOJQJ^J%jh*ha`CJOJQJU^Jh*ha`CJOJQJh*ha`CJOJQJ^J0jh*hPiCJOJQJU^JmHnHu+jk h*hPiCJOJQJU^Jh*hPiCJOJQJ^J%jh*hPiCJOJQJU^J0 2 \ pcV $If^gd1  $If^ gd1kd $$IfTl4  0.>+ t0  + 44 laf4pytET^ r t v      " ȯ񢒅rcMrrcrc7r+jh*hoI[CJOJQJU^J+j;h*hoI[CJOJQJU^Jh*hoI[CJOJQJ^J%jh*hoI[CJOJQJU^Jh*hCJOJQJh*hoI[5CJOJQJ^Jh*ha`CJOJQJ0jh*h^CJOJQJU^JmHnHu%jh*ha`CJOJQJU^J+jk h*ha`CJOJQJU^Jh*ha`CJOJQJ^J pcZZcZZUFf $Ifgd1 $If^gd1kd $$IfTl4  0.>+ t0  + 44 laf4pytET  ( R | $Ifgd1  $If^ gd1" $ ( * > @ B L N R T h j l v x | ~ ݘ݂l_h*hb CJOJQJ+jh*hoI[CJOJQJU^J+jUh*hoI[CJOJQJU^J+jh*hoI[CJOJQJU^J0jh*h^CJOJQJU^JmHnHu+jEh*hoI[CJOJQJU^Jh*hoI[CJOJQJ^J%jh*hoI[CJOJQJU^J kdi$$IfTl4  ֈ . $>+ /|  t0  + 44 laf4p<ytET .02<>BدŖ؃t^E8h*h|CJOJQJ0jh*hCc]CJOJQJU^JmHnHu+jh*hCc]CJOJQJU^Jh*hCc]CJOJQJ^J%jh*hCc]CJOJQJU^J0jh*h^CJOJQJU^JmHnHu+jMh*h*CJOJQJU^J%jh*h*CJOJQJU^Jh*h*CJOJQJ^J0h*h*5CJOJQJ^JfHq  B $Ifgd1 $If^gd1+ $If^ `gd1kdk$$IfTl4  \.~$>+k/P  t0  + 44 laf4p(ytET$&(248:NPR\^bdxz|߼~h~R~+j#h*h`CJOJQJU^J+jh*h`CJOJQJU^J0jh*h^CJOJQJU^JmHnHu+jOh*h`CJOJQJU^Jh*h`CJOJQJ^J%jh*h`CJOJQJU^Jh*hN5CJOJQJ^Jh*h`5CJOJQJ^Jh*hV5CJOJQJ^J  $Ifgd1 8%  $If^ gd1kd$$IfTl4  \.%>+zr$  t(0  + 44 laf4p(ytET8b<kd-$$IfTl4  \.%>+zr$ t0  + 44 laf4pytET $Ifgd1<>@TVXbdhj~ֽ֮~~~o\oF\\o\o+jy h*h CJOJQJU^J%jh*h CJOJQJU^Jh*h CJOJQJ^Jh*hN5CJOJQJ^Jh*h 5CJOJQJ^Jh*hV5CJOJQJ^Jh*h`CJOJQJ^J0jh*h^CJOJQJU^JmHnHu%jh*h`CJOJQJU^J+jh*h`CJOJQJU^J<>2kd-$$IfTl4  F., >+    t0  +     44 laf4pytET $If^ `gd1>h(K: $If^ `gd1kd"$$IfTl4  F., >+   t0  +     44 laf4pytET  $If^ gd1~ֽ֮v]J;h*hH=OCJOJQJ^J%jh*hH=OCJOJQJU^J0jh*hNbCJOJQJU^JmHnHu+j!h*hNbCJOJQJU^Jh*hNbCJOJQJ^J%jh*hNbCJOJQJU^Jh*h CJOJQJ^J0jh*h^CJOJQJU^JmHnHu%jh*h CJOJQJU^J+j h*h CJOJQJU^J"&*RTprtֽ֮~n^NB/N%j$hE^CJOJQJU^JhE^CJOJQJ^JjhE^CJOJQJU^Jh*h 5CJOJQJ^Jh*hop5CJOJQJ^Jh*hN5CJOJQJ^Jh*hV5CJOJQJ^Jh*hH=O5CJOJQJ^Jh*hH=OCJOJQJ^J0jh*hH=OCJOJQJU^JmHnHu%jh*hH=OCJOJQJU^J+j#h*hH=OCJOJQJU^J(*4@RxaTKKTK $Ifgd1  $If^ gd1kd#$$IfTl4  0.>+  t0  + 44 laf4pytETtvxzϑlϑVϑ+j(h*hH=OCJOJQJU^J+j'h*hH=OCJOJQJU^Jh*h1CJOJQJ^J0jh*hH=OCJOJQJU^JmHnHu+j%h*hH=OCJOJQJU^Jh*hH=OCJOJQJ^J%jh*hH=OCJOJQJU^Jh*h CJOJQJ^Jh*hopCJOJQJ^JkdI&$$IfTl4  r ., >+ /    t0  + 44 laf4p2ytETj $Ifgd1  $If^ gd1  hjl:Ddֽֽ֮֮֮ybKbKbK9#hthhE5CJOJQJ^JaJ,hthhr5B*CJOJQJ^JaJph,hthhE5B*CJOJQJ^JaJphh*hCJOJQJ^J+j)h*hH=OCJOJQJU^Jh*hH=O5CJOJQJ^Jh*hH=OCJOJQJ^J0jh*hH=OCJOJQJU^JmHnHu%jh*hH=OCJOJQJU^J+j )h*hH=OCJOJQJU^J kd*$$IfTl4  r .~$>+  / P    t(0  + 44 laf4p2ytET *TV|sbbbbb]P  $If^ gdFf- $If^ `gd1kd+$$IfTl4    >++  t 0    + 44 laf4p ytj>T $$Ifa$gdr  (*RVXtvx|~гЁkRг0jh*h*CJOJQJU^JmHnHu+j1h*h*CJOJQJU^J%jh*h*CJOJQJU^J%j/hECJOJQJU^JhECJOJQJ^JjhECJOJQJU^Jh'5CJOJQJ^Jh*h*CJOJQJ^Jh*h*5CJOJQJ^J hthhECJOJQJ^JaJ|:  $If^ gd468<@vͽ͎o\L<h*hb 5CJOJQJ^Jh*h5CJOJQJ^J%j7hCJOJQJU^J%j3hCJOJQJU^JhCJOJQJ^JjhCJOJQJU^J%jq2h6CJOJQJU^Jh6CJOJQJ^Jjh6CJOJQJU^Jh*h*CJOJQJ^JjhECJOJQJU^J%j1hECJOJQJU^J:<z& $If^ `gd1kd;$$IfTl4    rM~">+ t0    + 44 laf4p2ytETvxz|(*,68>BFΟΟsΟcSh*hN5CJOJQJ^Jh*h5CJOJQJ^J+j7>h*hb CJOJQJU^J+j=h*hb CJOJQJU^J0jh*hb CJOJQJU^JmHnHu+j=h*hb CJOJQJU^J%jh*hb CJOJQJU^Jh*hb 5CJOJQJ^Jh*hb CJOJQJ^Jz<>` $If^ `gd1Ff]@ $Ifgd1 F^`dh kUkEjhE^CJOJQJU^J+jcDh*hGN)CJOJQJU^J0jh*h^CJOJQJU^JmHnHu+jCh*hGN)CJOJQJU^J%jh*hGN)CJOJQJU^J%h*hGN)B*CJOJQJ^Jphh*hN5CJOJQJ^Jh*h5CJOJQJ^Jh*hGN)CJOJQJ^Jh*hGN)5CJOJQJ^J.C666  $If^ gd1kd{B$$IfTl4FX@ >+      t0+     44 laf4pytET &(*,048hjlpt³ssdQd;Q+jEHh*h2UCJOJQJU^J%jh*h2UCJOJQJU^Jh*h2UCJOJQJ^Jh*hh5CJOJQJ^Jh*h2U5CJOJQJ^Jh*hN5CJOJQJ^Jh*h5CJOJQJ^Jh*hGN)CJOJQJ^Jh*hCJOJQJ^JjhE^CJOJQJU^J%jDhE^CJOJQJU^JhE^CJOJQJ^J.0lXGG $If^ `gd1kdE$$IfTl4FX@ >+     t0+     44 laf4pytETaTT  $If^ gd1kdG$$IfTl40X>+    t0+ 44 laf4pytETBDFJxzŲtdTD4dTD4h*hi_5CJOJQJ^Jh*hN5CJOJQJ^Jh*h5CJOJQJ^Jh*hp5CJOJQJ^J0jh*h^CJOJQJU^JmHnHu+jHh*h2UCJOJQJU^Jh*h2UCJOJQJ^J%jh*h2UCJOJQJU^Jh*h2UCJOJQJ^J%jh*h2UCJOJQJU^J0jh*h^CJOJQJU^JmHnHuBxp__R  $If^ gd1 $If^ `gd1kdWI$$IfTl40X>+   t0+ 44 laf4pytETzȯ~hO?~~h*h2U5CJOJQJ^J0jh*h^CJOJQJU^JmHnHu+j]Lh*h2UCJOJQJU^Jh*h2UCJOJQJ^J%jh*h2UCJOJQJU^Jh*hi_CJOJQJ^J0jh*h^CJOJQJU^JmHnHu%jh*h2UCJOJQJU^J+jgJh*h2UCJOJQJU^Jh*h2UCJOJQJ^JI<<<3 $Ifgd1  $If^ gd1kdJ$$IfTl4FY X>+      t0+     44 laf4pytET "$&*NTֽ֮o_O?O,%jh*hCJOJQJU^Jh*htg5CJOJQJ^Jh*h5CJOJQJ^Jh*hN5CJOJQJ^Jh*h5CJOJQJ^Jh*hp5CJOJQJ^Jh*h|CJOJQJ^Jh*h2U5CJOJQJ^Jh*h2UCJOJQJ^J0jh*h^CJOJQJU^JmHnHu%jh*h2UCJOJQJU^J+jLh*h2UCJOJQJU^J "$  $If^ gd1 $If^ `gd1FfmO $Ifgd1 $&*ȯȯȯmȯ^Nh*h5CJOJQJ^Jh*hTCJOJQJ^J+jRh*hCJOJQJU^J+jqRh*hCJOJQJU^J+jQh*hCJOJQJU^J0jh*h^CJOJQJU^JmHnHu%jh*hCJOJQJU^J+j[Qh*hCJOJQJU^Jh*hCJOJQJ^J$&kdS$$IfTl4rX ~$>+$ 8    t 0+ 44 laf4p2ytET*.FHLPhjnr߭ߚЄkКUk+jVh*ht.PCJOJQJU^J0jh*h^CJOJQJU^JmHnHu+jyVh*ht.PCJOJQJU^J%jh*ht.PCJOJQJU^J%h*ht.PB*CJOJQJ^Jphh*h5CJOJQJ^Jh*ht.PCJOJQJ^Jh*ht.P5CJOJQJ^Jh*hN5CJOJQJ^J&Hj2kdWU$$IfTl4  FX@ >+    t0  +     44 laf4pytET $If^ `gd1FtK:: $If^ `gd1kdeX$$IfTl4  FX@ >+   t0  +     44 laf4pytET  $If^ gd1FJtx o\F\+jY_h*h<1CJOJQJU^J%jh*h<1CJOJQJU^J%j\hE^CJOJQJU^Jh*h<1CJOJQJ^Jh*h5CJOJQJ^Jh*h<15CJOJQJ^Jh*ht.P5CJOJQJ^Jh*hhCJOJQJ^J%jyWhE^CJOJQJU^JhE^CJOJQJ^JjhE^CJOJQJU^Jt(Rx  $If^ gd1Ff[ $If^ `gd1 "$(*>@BLNRTprtxzůşjZJZh*h5CJOJQJ^Jh*h|5CJOJQJ^J+j}ah*h<1CJOJQJU^J%j[`hE^CJOJQJU^JhE^CJOJQJ^JjhE^CJOJQJU^J+j_h*h<1CJOJQJU^Jh*h<1CJOJQJ^J%jh*h<1CJOJQJU^J0jh*h<1CJOJQJU^JmHnHuC22 $If^ `gd1kd b$$IfTl4  rM~">+ t0  + 44 laf4ytET hj$ݞ~r_~ݞK~r'h*h|CJOJQJ^JmHnHu%jdhE^CJOJQJU^JhE^CJOJQJ^JjhE^CJOJQJU^Jh*h5CJOJQJ^Jh*h|5CJOJQJ^J0jh*h|CJOJQJU^JmHnHu+j*ch*h|CJOJQJU^Jh*h|CJOJQJ^J%jh*h|CJOJQJU^Jh.gVVVM $Ifgd1 $If^ `gd1kdc$$IfTl4  0G>+  t 0  + 44 laf4pytET$&(0z| "ͻzzkz[Oh CJOJQJ^Jjh CJOJQJU^Jh*h[hCJOJQJ^Jh*h5CJOJQJ^Jh*h<15CJOJQJ^Jh*h<1CJOJQJ^J"h*h56CJOJQJ^J"h*h<156CJOJQJ^Jh*h|CJOJQJ^JjhE^CJOJQJU^J%jjehE^CJOJQJU^J.0+ $If^ `gd1kd$f$$IfTl4  \ G&>+x;F  t0  + 44 laf4p(ytET2kdg$$IfTl4FXH >+      t0+     44 laf4pytET $If^ `gd1   p t ܷܫܷtdtdtK0jh*h<1CJOJQJU^JmHnHuh*h5CJOJQJ^Jh*h<15CJOJQJ^J'h*h<1CJOJQJ^JmHnHu%jih CJOJQJU^Jh CJOJQJ^Jh*h<1CJOJQJ^J*jh CJOJQJU^JmHnHujh CJOJQJU^J%j0ih CJOJQJU^J p @/ $If^ `gd1kdPj$$IfTl4FXH >+      t 0+     44 laf4pytET  $If^ gd1p 0#  $If^ gd1kdk$$IfTl4FXH >+      t0+     44 laf4pytET $If^ `gd1 !!"!$!&!0!2!6!8!L!N!P!Z!\!b!d!x!˷o˅Y˅˷+joh*h<1CJOJQJU^J+j$oh*h<1CJOJQJU^J%jh*h<1CJOJQJU^Jh*h<1CJOJQJ^Jh*h<15CJOJQJ^J'h*h<1CJOJQJ^JmHnHu0jh*h<1CJOJQJU^JmHnHu6j6mh*h<1CJOJQJU^JmHnHu !6!</  $If^ gd1kdm$$IfTl4FXH >+        t 0+     44 laf4pytET $If^ `gd16!`!b!!#G:  $If^ gd1kd@p$$IfTl4FXH >+     t0+     44 laf4pytET $If^ `gd1x!z!!!!!!!!!!!p"r"####.#2#4#H#˷~n~\~M=M˷h*h<15CJOJQJ^Jh*h<1CJOJQJ^J#h*h<10J6CJOJQJ^Jh*h<16CJOJQJ^J(jh*h<16CJOJQJU^J"h*h56CJOJQJ^J"h*h<156CJOJQJ^J'h*h<1CJOJQJ^JmHnHu0jh*h<1CJOJQJU^JmHnHu6j~qh*h<1CJOJQJU^JmHnHu####.#0#_RIII $Ifgd1  $If^ gd1kd r$$IfTl40X>+ `   t0+ 44 laf4pytET0#2#\##  $If^ gd1kdCs$$IfTl4\' X>+ S    t(0+ 44 laf4p(ytETH#J#X#Z#\#^#r#t#v#z#|#############$˷|fˋ||Pˋ|@||h*h<15CJOJQJ^J+jvh*h<1CJOJQJU^J+juh*h<1CJOJQJU^Jh*h<1CJOJQJ^J%jh*h<1CJOJQJU^J0h*h<1B*CJOJQJ^JmHnHphp0u'h*h<1CJOJQJ^JmHnHu0jh*h<1CJOJQJU^JmHnHu6jth*h<1CJOJQJU^JmHnHu\#### $Ifgd1####  $If^ gd1kdv$$IfTl4\' X>+ S   t(0+ 44 laf4p(ytET$$$$$"$$$&$`$b$$$$$$$$$$$%%% %%ֽ֮֮xֽ֮`M%h*h<1B*CJOJQJ^Jph.jh*h<1B*CJOJQJU^Jph+jzh*h<1CJOJQJU^Jh*h5CJOJQJ^Jh*h<15CJOJQJ^Jh*h<1CJOJQJ^J0jh*h<1CJOJQJU^JmHnHu%jh*h<1CJOJQJU^J+jixh*h<1CJOJQJU^J#"$^$$ $If^ `gd1 $Ifgd1$$#kdx$$IfTl4\XH >+q S     t(0+ 44 laf4p(ytET$$%,%.%X%/kd{$$IfTl4FXH >+      t 0+     44 laf4pytET  $If^ gd1 $If^ `gd1% %"%&%(%*%.%0%D%F%H%R%T%V%X%Z%Ͱ͝{e{L{8(h*h<15CJOJQJ^J'h*h<1CJOJQJ^JmHnHu0jh*h<1CJOJQJU^JmHnHu+j}h*h<1CJOJQJU^J%jh*h<1CJOJQJU^Jh*h<1CJOJQJ^J%h*h<1B*CJOJQJ^Jph9jh*h<1B*CJOJQJU^JmHnHphu.jh*h<1B*CJOJQJU^Jph4j7{h*h<1B*CJOJQJU^JphZ%\%%%%%%%&&&.&0&2&6&8&L&N&P&T&V&Z&\&x&߼zdzKz0jh*h<1CJOJQJU^JmHnHu+jh*h<1CJOJQJU^J%jh*h<1CJOJQJU^J%j)hthCJOJQJU^JhthCJOJQJ^JjhthCJOJQJU^Jh*h<1CJOJQJ^J'h*h<1CJOJQJ^JmHnHuh*h<15CJOJQJ^Jh*h5CJOJQJ^JX%%%%&0kd}$$IfTl4FXH >+      t0+     44 laf4pytET $If^ `gd1&6&Z&&  $If^ gd1 $Ifgd1x&z&|&&&&&& ' '''''d'f''''''( :>@T͹܍z͙܍gͩe͙R%jh*h<1CJOJQJU^JU%jՃhthCJOJQJU^J%jhthCJOJQJU^JhthCJOJQJ^Jh*h<15CJOJQJ^Jh*h5CJOJQJ^J'h*h<1CJOJQJ^JmHnHuh*h<1CJOJQJ^JjhthCJOJQJU^J%jhthCJOJQJU^J&&&'d'5$$$ $If^ `gd1kde$$IfTl4\ XH >+,       t 0+ 44 laf4p(ytETd'''kd$$IfTl4    \uX&>+ F   t0    + 44 laf4p(ytET $If^ `gd1ess52. If Machine What Part? FORMTEXT       FORMTEXT       53. Initial Last Day Worked54. Initial Date Disability Began55. Initial Return to Work Date56. Return to Work Type Code*  FORMTEXT        FORMTEXT        FORMTEXT        FORMDROPDOWN 57. Return to Work With Same Employer? FORMDROPDOWN  58. Physical Restrictions Indicator FORMDROPDOWN  59. Signature of Authorized Employer or Representative60. Title61. Date Signed FORMTEXT       FORMTEXT       Instructions for EMPLOYER REPORT OF OCCUPATIONAL INJURY OR ILLNESS TO ALASKA DIVISION OF WORKERS COMPENSATION Employer: This form must be completed and sent immediately, and in no case later than ten (10) days after you have knowledge that your employee has been injured, or claims to have been injured or become ill while working for you. You have the option of completing this form electronically or by hand prior to sending the completed to your Insurer/Claims Administrator (Adjuster). The form should be submitted electronically via electronic data interchange (EDI). If you or your insurer is not registered and approved to submit reports electronically, mail this form (07-6101) and form 07-6100 to the Division of Workers Compensation, P.O. Box 115512, Juneau, AK 99811-5512. Make sure and keep a copy for your records. Failure to file this report within the required time may subject you and/or your insurer to a penalty equal to 20 percent of the amount of compensation due to the injured worker. AS 23.30.070 INFORMATION IN FILES MAINTAINED BY THE DIVISION OF WORKERS' COMPENSATION, EXCEPT FOR MEDICAL AND REHABILITATION RECORDS, IS AVAILABLE FOR PUBLIC REVIEW AND COPYING FOR NONCOMMERCIAL PURPOSES. AS 23.30.107 OSHA REQUIREMENTS Report industrial deaths and accidents to the Division of Labor Standards and Safety. Alaska Statute 18.60.058 requires employers to report to Division of Labor Standards and Safety any employment accident which is fatal to one or more employees or which results in the overnight hospitalization of one or more employees. The report, which must be made immediately, but no later than 8 hours after receipt by the employer of information that the accident has occurred, must relate the circumstances of the accident, the number of fatalities, and the extent of the injuries. Monday-Friday Alaska OSH (800) 770-4940 24-hour OSHA Hotline (800) 321-6742  Injury means accidental injury or death arising out of in the course of employment and an occupational disease, illness, or infection which arises naturally out of the employment or which naturally or unavoidably results from an accidental injury.  Injury does not include mental injury caused by stress unless it is established that (A) the work stress was extraordinary and unusual in comparison to pressures and tensions experienced by individuals in a comparable work environment, and (B) the work stress was the predominant cause of the mental injury. A mental injury is not considered to arise out of and in the course of employment if it results from a disciplinary action, work evaluation, job transfer, layoff, demotion, termination, or similar action taken in good faith by the employer. Alaska Division of Worker's Compensation Offices:Alaska Division of Labor Standards and Safety Offices:Anchorage:3301 Eagle Street, #304 Anchorage, AK 99503-4149 (907) 269-49803301 Eagle Street, #305 Anchorage, AK 99503-4149 (907) 269-4940 or (800) 770-4940Fairbanks:675 Seventh Avenue, Station K Fairbanks, AK 99701-4531 (907) 451-2889Juneau:1111 West 8th Street, #305 PO Box 115512 Juneau, AK 99811-5512 (907) 465-27901111 West 8th Street, #304 PO Box 111149 Juneau, AK 99811-1149 (907) 465-4855     07-6101 (Eff 07/22/2013) Page  PAGE 1 of  NUMPAGES 2 '<>fNAA  $If^ gd1kdU$$IfTl4    0X>+    t0    + 44 laf4pytET $If^ `gd1TVXbdfh|~ LNPRֽ֮qWGGGGh*h5CJOJQJ^J3jh*h<15CJOJQJU^JmHnHu.jh*h<15CJOJQJU^Jh*h<15CJOJQJ^J(jh*h<15CJOJQJU^Jh*h<1CJOJQJ^J0jh*h<1CJOJQJU^JmHnHu%jh*h<1CJOJQJU^J+jyh*h<1CJOJQJU^JNn]]]] $If^ `gd1kd$$IfTl4    0X>+   t0    + 44 laf4pytETR̽̎̽̽x̎̽h\Ih%jsh CJOJQJU^Jh CJOJQJ^Jjh CJOJQJU^J+j͋h*h<1CJOJQJU^J0jh*h<1CJOJQJU^JmHnHu+j+h*h<1CJOJQJU^Jh*h<1CJOJQJ^J%jh*h<1CJOJQJU^Jh*h15CJOJQJ^Jh*h<15CJOJQJ^J%  $If^ gdkd$$IfTl4    \z dO >+        t(0    + 44 laf4p(ytET 02;kd$$IfTl4    \z dO >+      t0    + 44 laf4pytET  $If^ gd *,.0246 ˻ˍ}m}ZK}m}Kh*hefCJOJQJ^J%j;hthCJOJQJU^Jh*h5CJOJQJ^Jh*hef5CJOJQJ^Jh*h1CJOJQJ^J%jhthCJOJQJU^JhthCJOJQJ^JjhthCJOJQJU^Jh*h<1CJOJQJ^Jjh CJOJQJU^J*jh CJOJQJU^JmHnHu2 $If^ `gd $If^ `gd1 Ͷt^tEtt0jh*h<1CJOJQJU^JmHnHu+jh*h<1CJOJQJU^J%jh*h<1CJOJQJU^Jh*hJV5CJOJQJ^Jh*h<1CJOJQJ^Jh*h<15CJOJQJ^Jh*h5CJOJQJ^J h*hefh*hefCJOJQJ^JjhthCJOJQJU^J%jhthCJOJQJU^J) $If^ `gd1kd%$$IfTl4    \ >+F    t0    + 44 laf4p(ytET2%  $If^ gd1kd$$IfTl4    FX$>+ #   t0    +     44 laf4pytET $If^ `gd1 NE/$7$8$H$]^a$gd 7$8$H$gd"kdG$$IfTl4    FX$>+   #   t0    +     44 laf4pytET  $If^ gd1 6ֽ֮ygyXC0%h*h`ZB*CJOJQJ^Jph(h*h`Z5B*CJOJQJ^Jphh*hPOJQJ^JaJ"h*h&I5OJQJ\^JaJ"h*hP5OJQJ\^JaJ"h*hP5CJOJQJ\^J h*h"CJOJQJ^JaJh*h<1CJOJQJ^J0jh*h<1CJOJQJU^JmHnHu%jh*h<1CJOJQJU^J+jh*h<1CJOJQJU^J @PV^`h íٚzgzWA+h*hK5B*CJOJQJ\^Jphh/B*CJOJQJ^Jph%h*hlB*CJOJQJ^JphhlB*CJOJQJ^JphhB*CJOJQJ^Jph%h*h/B*CJOJQJ^Jph+h*h~Z5B*CJOJQJ\^Jph+h*h5B*CJOJQJ\^Jph%h*h&IB*CJOJQJ^Jph%h*hB*CJOJQJ^Jph Z8: $$Ifa$gd $^a$gd&I$x7$8$H$^a$gd&I x7$8$H$gd$7$8$H$]^a$gd$7$8$H$]^a$gd$x7$8$H$a$gd&I $7$8$H$a$gd&I8:H`pӽӫo]o]oN?Nh*hwRCJOJQJ^Jh*hCJOJQJ^J"h*h&I5CJOJQJ\^J"h*h k15CJOJQJ\^Jh*h k1CJ"h*hhaO6CJOJQJ]^Jh*hhaOCJOJQJ^J"h*hhaO5CJOJQJ\^J+h*hK5B*CJOJQJ\^Jph+h*hK5B*CJOJQJ\^Jph+h*hwR5B*CJOJQJ\^Jph: $Tn^UU^U $Ifgdx$7$8$H$Ifgd$x$7$8$H$If]a$gd_dspkd$$IfTl4F ,"x t6    44 laf4ytT $Ifgd&I *HJ`n^^x$7$8$H$Ifgd$x$7$8$H$If]a$gd_dspkd$$IfTl4F ,"x t6    44 laf4ytT $Ifgd6:<>BDHJNPTbfz~û||kVkVCVk%h_PCJOJQJ^JaJmHnHu)jh h D CJOJQJU^JaJ h h D CJOJQJ^JaJh D CJOJQJ^JaJh)@CJOJQJ^JaJ h3h D CJOJQJ^JaJh*CJOJQJ^JaJh)jh)UhhF5CJOJQJ^JhhCJOJQJ^Jh*hCJOJQJ^Jh*h6CJOJQJ^J6R~8wg^^^g^^^ $Ifgdx$7$8$H$Ifgd$x$7$8$H$If]a$gd_dspkdm$$IfTl4F ,"x t6    44 laf4ytT 8:<@BFHLNRTytgd  0*gd gd3gd k1pkd$$IfTl4F ,"x t6    44 laf4ytT ¾hhF5CJOJQJ^Jh)h D %h_PCJOJQJ^JaJmHnHu h h D CJOJQJ^JaJ)jh h D CJOJQJU^JaJ gd k16&P1h:p>/ =!"#$%hh $$If!vh5J 5`#vJ #v`:V l4 t0  +,5J 5`/ / /  f4yts)T$$If!vh5+#v+:V l4  t 0  +,5+/ f4p yts)TDIndustryNAICSCodeZ$$If!vh5558#v#v#v8:V l4  t 6 0  +++,5558/ / /  / / e4f4pyt9JD( EmployerNameX$$If!vh5558#v#v#v8:V l4 t 6 0  +++,5558/ / / / /  / / e4f4pyt9J.$$If!vh55Y5^#v#vY#v^:V l4  t0  + ,55Y5^/ / / f4pytETD( ERContactNameDContactTelephoneD EmployerFEINDEmployerUINumber2$$If!vh55Y5Y5^#v#vY#v^:V l4 t0  + ,55Y5^/ / / / / f4p(ytET$$If!vh55#v#v:V l4  t0  + ,55/ / / / f4pytETD(ERMailingAddress1D(ERPhysicalAddress1$$If!vh55#v#v:V l4 t0  + ,55/ / / f4pytETD(ERMailingAddress2D(ERPhysicalAddress2$$If!vh55#v#v:V l4 t0  + ,55/ / / f4pytET0$$If!vh5 55/5| 55#v #v#v/#v| #v#v:V l4  t<0  + ,5 55/5| 55/ / / / / / / / / / / / f4p<ytET(kd$$IfTl4  ֈ . $>+ /|   t<0  + 44 laf4p<ytETD ERMailingCityDERMailingStateD ERMailingZipCodeDERPhysicalCityDERPhysicalStateD ERPhysicalZipCode$$If!vh5 55/5| 55#v #v#v/#v| #v#v:V l4 t0  + ,5 55/5| 55/ / / / / / / / / / / / f4p<ytETDERMailingCountryCodeDERPhysCountryCode$$If!vh5k5/5P5#vk#v/#vP#v:V l4  t0  + ,5k5/5P5/ / / / /  / / / f4p(ytETL$$If!vh55z5r5$#v#vz#vr#v$:V l4  t(0  + ,55z5r5$/ / f4p(ytETjD(jDDEEMiddleInitialD EENameSuffix$$If!vh55z5r5$#v#vz#vr#v$:V l4 t0  + ,55z5r5$/ f4pytETJ$$If!vh55 5 #v#v #v :V l4  t0  + ,55 5 /  / / / / f4pytETD(EEMailingLine1D EEDOBM/d/yyyyD EEDateOfDeathM/d/yyyy$$If!vh55 5 #v#v #v :V l4 t0  + ,55 5 / / / f4pytETD(EEAMailingLine2$$If!vh55#v#v:V l4  t0  + ,55/ / / f4pytET"Df EEIDTypeDD SELECT ONEE Employment VISA G Green Card P PassportS Social Security Number ~D EEIDNumber$$If!vh5 55/5 5 #v #v#v/#v #v :V l4  t0  + ,5 55/5 5 /  / / / / / / / f4p2ytETD EEMailingCityDEEMailingStateD EEMailingZipCodeDEEMailingCountry$$If!vh5 55/5P5#v #v#v/#vP#v:V l4  t(0  + ,5 55/5P5/  / / / /  f4p2ytET$$If!vh5+#v+:V l4  t 0    + ,5+f4p ytj>T`$$If!vh55555#v#v#v#v#v:V l4  t20    + ,55555f4p2ytETkdc,$$IfTl4    rM~">+  t20    + 44 laf4p2ytETXDfMTCRptDD SELECT ONE 00-Original 01-Cancel 02-Change 04-DenialAQ-Acquired ClaimAU-Acquired Unallocated CO-CorrectionrDJCN0Df ClaimStatusDD SELECT ONEO-OpenC-ClosedR-ReOpenX-ReOpen/ClosedrDf ClaimTypeDD SELECT ONEM Medical OnlyI Lost Time/IndemnityN Notification OnlyB Became Medical OnlyL Became Lost Time/IndemnityDf LateReasonDD DROP L1 No ExcuseL2 Late Notification, EmployerL3 Late Notification, Employee+L4 Late Notification, Jurisdiction Transfer*L5 Late Notification, Health Care Provider#L6 Late Notification, Assigned RiskL7 Late Investigation/L8 Technical Processing Delay, Computer FailureL9 Manual Processing Delay0LA Intermittent Lost Time Prior to First Payment,LB Late Notify/Pay Due to a Natural Disaster-LC Late Notify/Pay Due to an Act of Terrorism"D DOWN LISTC1 Coverage Lack of Information(E1 Wrongful Determination of No CoverageE2 Errors from EmployerE3 Errors from EmployeeE4 Errors from Jursidication#E5 Errors from Health Care Provider'E6 Errors from Other Claim Admin/IA/TPAD1 Dispute Concerning Coverage-D2 Dispute Concerning Compensability in Whole,D3 Dispute Concerning Compensability in Part)D4 Dispute Concerning Disability in Whole(D5 Dispute Concerning Disability in Part D6 Dispute Concerning Impairment$$If!vh55555#v#v#v#v#v:V l4 t0    + ,55555f4p2ytETD PolicyNumberD PolicyEffectDateM/d/yyyyD PolicyExpireDateM/d/yyyy$$If!vh5 5M5,5L55v#v #vM#v,#vL#v#vv:V l4  t20  +,5 5M5,5L55v/ f4p<ytETkd>$$IfTl4  ֈf +#K+ M,Lv  t20  +44 laf4p<ytETf$$If!vh55 5 #v#v #v :V l4  t0+ ,55 5 /  /  / / / / /  f4pytETD( InsurerNameD InsurerFEINDf InsurerTypeDD SELECT ONE I InsurerS Self-InsurerG Guarantee Fund <$$If!vh55 5 #v#v #v :V l4 t0+ ,55 5 /  /  / / / / /  f4pytET,$$If!vh55#v#v:V l4  t0+ ,55/  / / / / /  f4pytETD(ClaimAdminNameD(CAMailingAddress1$$If!vh55#v#v:V l4 t0+ ,55/  /  / / / /  f4pytETD(CAMailingAddress2h$$If!vh5 5 5#v #v #v:V l4  t0+ ,5 5 5/  /  / / / / / /  f4pytETD ClaimAdminFEINDClaimAdminClaimNumbe$$If!vh5 5 58 55#v #v #v8 #v#v:V l4  t20+ ,5 5 58 55/  / / / / / / / / / /  f4p2ytETkduM$$IfTl4rY X ~$>+  8    t20+ 44 laf4p2ytETD CAPhysicalPostalCodeD CAMailingCityDCAMailingStateD CAMailingZipCode$$If!vh5$558 55#v$#v#v8 #v#v:V l4  t 0+ ,5$558 55/  / /  / / / /  / / / / /  f4p2ytET $$If!vh55 5 #v#v #v :V l4  t0  + ,55 5 / / f4pytETD( InsuredNameD InsuredFEINDf InsuredTypeDD SELECT ONE I InsuredS Self-Insured U Uninsured $$If!vh55 5 #v#v #v :V l4 t0  + ,55 5 / / f4pytET$$If!vh55555#v#v#v#v#v:V l4  t20  + ,55555/  / / / / f4p2ytETkd]Y$$IfTl4  rM~">+  t20  + 44 laf4p2ytETjDfEmploymentStatusDD SELECT ONEC Piece Worker9 Volunteer Worker8 Seasonal WorkerA Apprenticeship Full-timeB Apprenticeship Part-time1 Regular/Full-time Employee2 Part-time Employee3 Unemployed/Not Employed 6 Retired 4 On Strike 5 Disabled7 Other DDaysWorkedPerWeekvDEEWage"DfFROIWagePeriodCodeDDDROP DOWN LIST 01 Weekly 02 Bi-Weekly 04 Monthly06 Daily 07 Hourly D EEHireDateM/d/yyyy$$If!vh55555#v#v#v#v#v:V l4 t0  + ,55555/  / / / f4ytETD EEOccupation$$If!vh55#v#v:V l4  t 0  + ,55/ / / / f4pytETDfFullWagePaidDD DROP DOWNY YesN No DfERPaidInLieuDD SELECT ONEY YesN No $$If!vh5x5;55F#vx#v;#v#vF:V l4  t0  + ,5x5;55F/ / / / / / / / f4p(ytETt$$If!vh55 5 #v#v #v :V l4  t0+ ,55 5 /  / / / / / / /  f4pytETD InjuryDateM/d/yyyyD InjuryTime h:mm am/pm`$$If!vh55 5 #v#v #v :V l4  t 0+ ,55 5 / /  / / /  / / /  f4pytET$$If!vh55 5 #v#v #v :V l4  t0+ ++,55 5 / /  / /  / / / /  f4pytETD2AccidentSiteOrgName\$$If!vh55 5 #v#v #v :V l4  t 0+ ++,55 5 /  / / / / / /  f4pytETD DateERKnewM/d/yyyyD DateCAKnewM/d/yyyy<$$If!vh55 5 #v#v #v :V l4 t0+ ,55 5 /  / / / / / /  f4pytETD(AccidentSiteStreet5$$If!vh55#v#v:V l4  t0+ +,55/ /  / / / /  f4pytET$$If!vh5 55S5#v #v#vS#v:V l4  t(0+ +,5 55S5/  / / / / / / / /  f4p(ytETDAccidentSiteCityDAccidentSiteStateD AccidentSiteZipCode$$If!vh5 55S5#v #v#vS#v:V l4  t(0+ +,5 55S5/  / / / / / / / / /  f4p(ytETDAccidentSiteCountry$$If!vh5q5S5 5 #vq#vS#v #v :V l4  t(0+ ,5q5S5 5 /  /  / / /  / / / /  f4p(ytETDBodyPartAffectedD InjuryNature`$$If!vh55 5 #v#v #v :V l4  t 0+ ,55 5 / /  / / /  / / /  f4pytETD2InjuryLocation$$If!vh55 5 #v#v #v :V l4  t0+ ,55 5 / /  / / / / / / /  f4pytETDfAccidentPremiseCodeD SELECT ONE E EmployerL LesseeX Other D InjuryCauseDf DeathResultDDDROP DOWN LISTY YesN No U Unknown $$If!vh5, 5 5 5 #v, #v #v #v :V l4  t 0+ ,5, 5 5 5 /  /  / /  / / / / / / /  f4p(ytETDfMachineProductFailDD DROP DOWNY YesN No DfGuardsProvidedDD DROP DOWNY YesN No $$If!vh5555F#v#v#v#vF:V l4  t0    + ,5555F/  / / /  / / / / / / /  f4p(ytET"$$If!vh55#v#v:V l4  t0    + ,55/  /  / / /  f4pytETD2 AccidentLine9D2AccidentLine10$$If!vh55#v#v:V l4 t0    + ,55/  / / / / /  f4pytET$$If!vh5 5 5 5 #v #v #v #v :V l4  t(0    + ,5 5 5 5 /  /  / / / / /  f4p(ytETD InitialLastDayWorkedM/d/yyyyD InitialDateDisabilit h:mm am/pmD InitialReturnToWorkM/d/yyyyDf RTWCodeDDDROP DOWN LISTA ActualR Released to Work L$$If!vh5 5 5 5 #v #v #v #v :V l4 t0    + ,5 5 5 5 /  / / / / / /  f4pytETDf RTWSameERDD DROP DOWNY YesN No 8DfPhysicalRestrictionsDROP DOWN LIST No Without Physical RestrictionsYes With Physical Restrictions |$$If!vh55F5 5 #v#vF#v #v :V l4  t0    + ,55F5 5 / / / / / / f4p(ytETX$$If!vh555##v#v#v#:V l4  t0    + ,555#/  /  / / / /  f4pytETD InitialDateDisabilit h:mm am/pmD InitialReturnToWork h:mm am/pm6$$If!vh555##v#v#v#:V l4 t0    + ,555#/  /  / / / /  /  f4pytETu$$If!vh5x55#vx#v:V l4 t65x5f4ytTu$$If!vh5x55#vx#v:V l4 t65x5f4ytTu$$If!vh5x55#vx#v:V l4 t65x5f4ytTu$$If!vh5x55#vx#v:V l4 t65x5f4ytT666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH666666666666666666666666666666666666666666666666666666666666666666<@<  .NormalCJ_HmH sH tH DAD Default Paragraph FontRi@R 0 Table Normal4 l4a (k( 0No List jj %V Table Grid7:V0f\f 0 z-Top of Form$&dPa$<CJOJQJ^JaJFF 0 Char Char4<CJOJQJ^JaJl]l 0z-Bottom of Form$$dNa$<CJOJQJ^JaJF1F 0 Char Char3<CJOJQJ^JaJ4B4 30Header  H$2Q2 30 Char Char2CJ4 @b4 30Footer  H$2q2 30 Char Char1CJJ^J %0 Normal (Web)dd[$\$PJaJ@Z@ P,0 Plain TextCJOJQJaJ<< P,0 Char CharCJOJQJaJ6U@6 E10 Hyperlink >*B*ph. z zp4X+(1>?Ti~$%*09>DMNcu(;<SY`gh}*?@Uuv{)*  4GZ~":;Pexy  2 3 H ] b h q r   . / D Y l m  2 3 N c d 4 R o p  G H _ ` g | cdioyz01Sewx!"Wi)*Fh!4XklZ01&\V}~ $3Kdv  /JXn}~r fr fr f*@9?9@9@9`@9?9@9?9@9@9@9?9@9@9@9@9?9@98@9?9@98@9?9@98@9?9 @9@9W@9 @9@9@9?9 @9@9W@9 @9@9@9?9@9W@9x@9@9?9@9@9@9L@9?9@9@9@9L@9?9@9& @9: @9?9@9& @9: @9?9@98@9?9 @9@9W@9& @9: @9?9 @9@9W@9x@9@9?9*SR@9@9@9@9@92b@9@9@9@9@92b @9u@9T@9t@9@9@9?9@9 @9& @9?9@9 @9& @9?9@9@9?9@9@9?9 @9' @9@9?9 @9' @9` @9@9@9?9L@9@9` @9@9@9?9@9 @9& @9?9@9 @9& @9?9@9@9@9@9@9?9@9@9@9@9@9?9@9@9?9@9c@9@9n@9r@9 @9 @9?9@9 @9 @9?9@9 @9 @9?9@9?9@9 @9 @9?9@9@9?9 @9@9{@9?9 @9@9{@9?9@9{@9 @9 @9?9@9 @9 @9?9@9 @9 @9?9T @9 @9 @9 @9?9 @9 @9@9n@9?9@9@9?9@9@9?9 @9 @9 @9 @9?9 @9 @9 @9 @9?9= @9n@9 @9 @9?9@9 @9K@9?9@9 @9K@9?90*s0*v:0*v:0*v:0*v:0*v:0*v:0*v:0*v:0*v:0*v:0*v:0*v:0*v:0*v:v:8 v:8 v:tv:8 v:8 v:8 v:8 v:8 v:8 v:8 v:~ v:8 v:8 v:8 v:8 v:v:8 v:8 v:8 v:8 v:8 v:8 v:8 v:8 v:~ 0*v:0*^4X+(1>?Ti~$%*09>DMNcu(;<SY`gh}*?@Uuv{)*  4GZ~":;Pexy  2 3 H ] b h q r   . / D Y l m  2 3 N c d 4 R o p  G H ] ^ _ ` g | cdioxyz01Sewx!"Wi)*Fh!4XklZ01&\V}~ $3Kdv  /JXn}~0ȑ0ȑ0 ȑ0  ȑ0 ȑ0ȑ0ȑ0  ȑ0  ȑ0  ȑ0  ȑ0  ȑ0ȑ0ȑ0 ȑ0 ȑ0 ȑ0 ȑ0 ȑ0 ȑ0 ȑ0 ȑ0 ȑ0 ȑ0 ȑ0 ȑ0 ȑ0 ȑ0 ȑ0 ȑ0 ȑ0 ȑ0 ȑ0 ȑ0 ȑ0 ȑ0 ȑ0 ȑ0  ȑ0  ȑ0  ȑ0  ȑ0" ȑ0" ȑ0" ȑ0" ȑ0$ ȑ0$ ȑ0$ ȑ0$ ȑ0& ȑ0& ȑ0& ȑ0( ȑ0( ȑ0( ȑ0* ȑ0* ȑ0, ȑ0, ȑ0, ȑ0, ȑ0, ȑ0. ȑ0. ȑ0. ȑ0. ȑ0. ȑ00 ȑ02 ȑ02 ȑ02 ȑ02 ȑ02 ȑ04 ȑ04 ȑ04 ȑ04 ȑ04 ȑ06 ȑ06 ȑ06 ȑ06 ȑ06 ȑ06 ȑ08 ȑ08 ȑ08 ȑ0: ȑ0: ȑ0: ȑ0< ȑ0< ȑ0> ȑ0> ȑ0@ ȑ0@ ȑ0@ ȑ0B ȑ0B ȑ0B ȑ0B ȑ0B ȑ0D ȑ0D ȑ0D ȑ0D ȑ0D ȑ0F ȑ0F ȑ0F ȑ0H ȑ0H ȑ0H ȑ0J ȑ0J ȑ0J ȑ0J ȑ0J ȑ0L ȑ0L ȑ0L ȑ0L ȑ0L ȑ0N ȑ0N ȑ0P ȑ0P ȑ0P ȑ0P ȑ0R ȑ0R ȑ0R ȑ0T ȑ0T ȑ0T ȑ0V ȑ0&ȑ0V ȑ0X ȑ0$ȑ0X ȑ0Z ȑ0Z ȑ0Z ȑ0\ ȑ0\ ȑ0^ ȑ0^ ȑ0^ ȑ0^ ȑ0` ȑ0` ȑ0` ȑ0` ȑ0b ȑ0b ȑ0b ȑ0b ȑ0d ȑ0d ȑ0d ȑ0f ȑ0f ȑ0f ȑ0h ȑ0h ȑ0h ȑ0h ȑ0j ȑ0j ȑ0j ȑ0j ȑ0l ȑ0l ȑ0n ȑ0n ȑ0p ȑ0p ȑ0p ȑ0p ȑ0r ȑ0r ȑ0r ȑ0r ȑ0t ȑ0t ȑ0t ȑ0t ȑ0v ȑ0v ȑ0v ȑ0x ȑ0x ȑ0x ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0 ȑ0 ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0ȑ0uȑ0uȑ0uȑ0uȑ0uȑ0uȑ0uȑ0uȑ0ȑ0 IIIL? B h  ^ " ~tvF z* $ x!H#$%Z%x&TR !#&(+/2358;=?ACFHJLNQSUWZ]`cfjkn  @ d 0  8>(|:z.$&t.p 6!#0#\###$$X%&&d''2:8 "$%')*,-.014679:<>@BDEGIKMOPRTVXY[\^_abdeghilmop`?KQT`fiu{~ !NZ`coru(48htz} !'*6<@LR"& +14DGWZjl|;GMP\beu ) / 3 ? E H T Z / ; A D P V Y i     ) / N Z ` H T Z g s y | azS_beqtx Wg  &!1XhXFtFtFtFtFtFtFFFFtFFFFtFtFtFF4FTFTFTFTFFTF4FS FtFFFFS FTS$S$S$S$FFFFFS FFFFFFFFFFFS S FFS FtFS S FFFFFFXFFFFF4F4FS F4S S S FF4FFFS S S FF*138DFL!@  @ 0(  B S  ?H0(  $ EmployerName EmployerFEINEmployerUINumberERPhysicalAddress1ERPhysicalAddress2ERMailingCountryCodeERPhysCountryCodeEEMiddleInitial EENameSuffix EEDateOfDeath EEIDTypeDDEEMailingZipCodeMTCRptDD ClaimStatusDD ClaimTypeDD LateReasonDD InsurerTypeDD InsuredTypeDDEmploymentStatusDDFROIWagePeriodCodeDDFullWagePaidDDERPaidInLieuDD InjuryDate InjuryTimeBodyPartAffected InjuryNatureAccidentPremiseCodeD InjuryCause DeathResultDDMachineProductFailDDGuardsProvidedDDAccidentLine10InitialReturnToWork RTWCodeDD RTWSameERDDPhysicalRestrictionsi~(* 4GZeY SeW!X  !"#|"9=EXkvj  cu h'2i?_v !cv !`v Է!av !bv !dv gor}}''77  ##JJTXcc IIPW^bmm  !#$"%&'(*+),-./021453678:9<=;>B9*urn:schemas-microsoft-com:office:smarttagscountry-region9:*urn:schemas-microsoft-com:office:smarttagsplace:;*urn:schemas-microsoft-com:office:smarttagsStreet><*urn:schemas-microsoft-com:office:smarttags PostalCode9=*urn:schemas-microsoft-com:office:smarttagsState8>*urn:schemas-microsoft-com:office:smarttagsCity;?*urn:schemas-microsoft-com:office:smarttagsaddress d?;>=<:9:9:9:9:=?;>=<:=:=:>?;:>=<?;:>=<:>::>=<:>?;?;:>=<?;?;:>=< ,2evy{Y j m o    * 0 3 5      "$Whik!246Xiln~ai%::.?**   4EGXevY j  Wh!2XiB,,00AAFF~D9E6" 8*-4wc:bTX ^ Ah R6 F GR p := v 8 0\I^h} gIY"&/%'3A:vI`IA;gu}$Uv{|O #-F5x.ODc9JB N)U D V Z b s l!7P!;#C#x#U$6%%U%[%'yL' (C(X(Rk(GN)$T*rl*aV+tl+y+2,L;,Nv,J-1u-H.H]/Uw/!61<1 k12c29340.45 <5J7f7=l7m7Q85R8mj8):9:}:;T;Ql;b<=Q=sE>j>K?[p?r@lUl_lrolmN"n;n5Qn}ne/oop:)q'r_dstd.tXEvOv_vHwxpxy%y8yP{*?|.~u~5 ^DppsUtq(28KP0WRX  *;9Pq}t .}h:lNV~?nNlUE6@TnaU.^k^.)F!* Zci=#(D/h1* A *<@Bvx&%V UFb\W+Ce(!)nw!,8L6tZ]S*HYPiW*WC.im36c9f| ! P,I.2zZe^[a s &3[= kD!1Gm*xeCAKc>PjD&k8#h'9;KT * .O C^!]a1 v} *'D=/E^iJ5;A@@ N46m[@ @^ s),+2 7@mg%1`#/_fpENj@fp'u7V=',[-Q!e voF"{lpstEo$;()Qt^ nFI:Ch 7@DKuze `(OUh&SNy:/kTwxm!')@~.shoBrb]a*<g (|[hc @S$U-lo> H|i3^cf+E #'f.'>4r^E1c{:R `xg k5nz# 'N.SOJKF1}EZIblri]bGu+(1>?Ti~$%*09>DMNcu(;<SY`gh}*?@Uuv{)*  4GZ~":;Pexy  2 3 H ] b h q r   . / D Y l m  2 3 N c d 4 R o p  G H ] ^ _ ` g | cdioxyz01Sewx!"Wi)*Fh!4Xkl\V}~3/}~@ ߋ `@` ` `````````` `"`$`&`UnknownGz Times New Roman5Symbol3& z ArialA& Arial Narrow7.@Calibri9=  @ Consolas"1h(G(GCg997 !24doo-q3QHX)$P%V*3ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENTbwscmlsInformation ServicesOh+'0 0< \ h t 4ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENTbwscmls Normal.dotInformation Services2Microsoft Office Word@@@=L@4@4՜.+,D՜.+,d  hp  DOLWD9o' 4ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Title 8@ _PID_HLINKSA\ ^Fhttps://www.wcio.org/Document Library/InjuryDescriptionTablePage.aspxPE2http://www.census.gov/cgi-bin/sssd/naics/naicsrch  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !#$%&'()+,-./0167B:;<=>?@ACHDEFGIRoot Entry FE9Data [1TablexWordDocument8.SummaryInformation("DocumentSummaryInformation8*Macros E tEVBA E@EThisDocument __SRP_2__SRP_3 g_VBA_PROJECT   !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGIJKLMNOPQRSUVWXYZ[\]^_`abcdefghijlopqrstvVX;)<%Ph kA1m"y̲M :KqW-YC{EKNxC{EKN%Ph kA1m"yME(S"SS"6"(1Normal.ThisDocument  ` h@% % % @@x@pU$*\Rffff*0555abe5c24" ophŰAttribute VB_Name = "ThisDocument" Bas1Normal.VGlobal!SpaclFalse CreatablPre declaIdTru BExposeTemplateDeriv$CustomlizC1P Sub ComboBox1_Change() End rU 0)Qy 4a[0   XrU @$`nay  *\G{000204EF-0000-0000-C000-000000000046}#4.0#9#C:\PROGRA~1\COMMON~1\MICROS~1\VBA\VBA6\VBE6.DLL#Visual Basic For Applications*\G{00020905-0000-0000-C000-000000000046}#8.3#0#C:\Program Files\Microsoft Office\OFFICE11\MSWORD.OLB#Microsoft Word 11.0 Object Library*\G{00020430-0000-0000-C000-000000000046}#2.0#0#C:\WINDOWS\system32\stdole2.tlb#OLE Automation*\CNormal*\CNormalJ\S(*\G{2DF8D04C-5BFA-101B-BDE5-00AA0044DE52}#2.3#0#C:\Program Files\Common Files\Microsoft Shared\OFFICE11\MSO.DLL#Microsoft Office 12.0 Object Library*\G{0D452EE1-E08F-101A-852E-02608C4D0BB4}#2.0#0#C:\WINDOWS\system32\FM20.DLL#Microsoft Forms 2.0 Object Library*\G{868A2E77-E1F4-4FA4-9B6C-27343E9DC66A}#2.0#0#C:\DOCUME~1\aperrigo\LOCALS~1\Temp\Word8.0\MSForms.exd#Microsoft Forms 2.0 Object Library.E .`M   UX;ThisDocument0555abe5c2ThisDocument)  g?`TLh"R㉸`%WordkVBAWin16~Win32MacVBA6#Project-stdole`NormalOfficeuMSFormsC ThisDocument< _EvaluateComboBox1_ChangeaDocumentj`  dirH__SRP_0 T__SRP_1kfPROJECTwmm)0* pHdProjectQ(@= l U J< rstdole>stdoleP h%^*\G{00020430-C 0046}#2.0#0#C:\WINDOWS\system32\e2.tlb#OLE Automation`ENormalENCrmaQF  * \C J\S!OfficgOficg!G{2DF8D04C-5BFA-101@B-BDE5gAjAe42ggram Files\CommonMicrosoft Shared\OFFICE11\MSO.DLL#M 1 Ob Library%xMSFAs>AMSFBs$3@dD452EE1-E0D8F0A-8-02608C4D0BB4dFM20L'B &/;"1D|~ C00}#0B# 50 A868A2E77-E1F4-4FA4-9B6C-27343E9 DC66A6DOCUME~1\aperrigo\@LOCALS@Temp\Word8.0c8.exdd=".E .`M AX;ThisDocumentGTisDlcuen* 2` H1By "E,)""+K*y *\CNormalrU~~~~~~~~h 9VO3W  a 9  ٷ3wB y~)Project ThisDocumentF /C:\PROGRA~1\COMMON~1\MICROS~1\VBA\VBA6\VBE6.DLLVBA  1` F5C:\Program Files\Microsoft Office\OFFICE11\MSWORD.OLBWord )p0FC:\WINDOWS\system32\stdole2.tlbstdole 9L-[DR?C:\Program Files\Common Files\Microsoft Shared\OFFICE11\MSO.DLLOffice 1.E .`M C:\WINDOWS\system32\FM20.DLLMSForms ))Qw.Ol'4>j6C:\DOCUME~1\aperrigo\LOCALS~1\Temp\Word8.0\MSForms.exd )1k F%Ph kA1m"yM :KqW-YC{EKN FDocumentComboBox1_Change @urU~}  pThisDocumentThisDocumentID="{FA973B97-00F7-4E76-BCA8-0457FEBA7442}" Document=ThisDocument/&H00000000 Name="Project" HelpContextID="0" VersionCompatiPROJECTnCompObjuqble32="393222000" CMG="4B49B30AFA0EFA0EFA0EFA0E" DPB="96946EC7F2593C5A3C5A3C" GC="E1E319DA1ADA1A25" [Host Extender Info] &H00000001={3832D640-CF90-11CF-8E43-00A0C911005A};VBE;&H00000000 &H00000002={000209F2-0000-0000-C000-000000000046};Word8.0;&H00000000 [Workspace] ThisDocument=30, 30, 1022, 530, C   FMicrosoft Office Word Document MSWordDocWord.Document.89q