wc6105.doc - THIS NOTICE IS FROM THE INSURER/EMPLOYER KEEP...

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THIS NOTICE IS FROM THE INSURER/EMPLOYER. KEEP IT FOR YOUR RECORDS. EMPLOYEE: READ IMPORTANT INFORMATION ABOUT YOUR RIGHTS ON BACK ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Alaska Workers’ Compensation Board P.O. Box 115512 Juneau, Alaska 99811-5512 CONTROVERSION NOTICE AWCB Case Number: INSURER/EMPLOYER: This form is required if you desire to controvert (deny) payment of benefits. Complete and mail the original to the employee with a copy to the Alaska Workers' Compensation Board. 1. Employee’s Name (Last, First, Middle Initial) 2. Insurer Claim No. 3. Injury Date 4. Address 5. Date of Employer’s First Knowledge 6. Social Security Number City Stat e Zip Code Telephone 7. Birth Date 8. Employer 9. Insurer/Adjusting Company 10. Address 11. Address City Stat e Zip Code Telephone City Stat e Zip Code Telephone 12. Nature of Alleged Injury or Illness Under the provisions of AS 23.30.155 the employer/insurer gives notice that the right to the benefit(s) described below is controverted (denied) on the following grounds: Type of Benefits Controverted (Denied) Reason for Controverting-State specific reasons and describe the evidence relied upon and not merely conclusions. The controversion must have valid factual or legal objections to the payment of benefits.
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