Form 07-6120 (Revised 01/2007)
EMPLOYER’S NOTICE
OF INSURANCE
TO THE EMPLOYEES OF THE UNDERSIGNED:
Your employer is insured by
Insurer
Street and Number
City
State
Zip Code
For the period from
Through
Adjusting Company
Street and Number
City
State
Zip Code
Telephone
This insurance pays benefits for job-connected injuries, illnesses or death as provided by the Alaska Workers’
Compensation Act
Employer
By
Title
Witness
Witness
Immediately (not later than 30 days from injury or death date) give your employer and the Alaska Workers’
Compensation Division written notice of a job-related injury, illness, or death. Get the “Report of Occupational Injury or
Illness” form from your employer for this purpose.
If you have questions about your rights or benefits under the Alaska Workers’ Compensation Act, contact the insurer at
the above address and the Alaska Workers’ Compensation Division at the nearest office listed below:
ANCHORAGE
FAIRBANKS
JUNEAU
PO Box 107019
3301 Eagle St Ste 304
Anchorage AK 99510-7019
(907) 269-4980
675 7th Ave
Station K
Fairbanks AK 99701-4531
(907) 451-2889
PO Box 115512
1111 W 8th St Rm 307
Juneau AK 99811-5512
(907) 465-2790
NOTICE TO EMPLOYER: AS 23.30.060 requires that you post this notice in three conspicuous place on the employer’s
premises.