Please Note
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Forms
Anyone not a state employee trying to file a claim, please contact a claims administrator at 465-2180 or RiskManagement@alaska.gov.
Volunteer Service Agreement Forms
Report of Occupational Injury or Illness
- Employee Report to Employer - Form 07-6100 (word)
- Employer Report to Division of Workers' Compensation - Form 07-6101 (word)
- Example - Form 07-6101 (pdf)
- Third-Party Claims Administrator:
Penser North America Inc.
PO Box 241148
Anchorage, AK 99524
Toll Free: 1-844-463-2727
Main: (907)313-7650
Fax: (907)302-3803
Liability Accident Notice
A Liability Accident Notice (LAN) form should be completed if any injury or damages are incurred involving a State owned or leased vehicle operated by a state employee, State property is damaged, or allegations of wrongdoing by a State employee or official have been made. If the occurrence involves death or serious injury, notify Risk Management immediately.
Timely recording of the known facts is vital and necessary to assist Risk Management in promptly investigating and resolving claims. Please submit completed LANs, damage pictures, and other related documents to RiskManagement@alaska.gov.
Other Common Forms
- Division of Marine Highways Accident/Illness Report (PDF)
- Employee's/Master Report of Maritime Injury or Illness (PDF)
- AMHS Vehicle Accident/Property Damage Report (PDF)
- AMHS Vehicle Accident/Property Damage Report Instructions (PDF)
- Pilot Qualification Certification (PDF)
- Supervisor Accident Investigation Report (PDF)
- Volunteer Accident Report (PDF)