Please Note
You must be inside the state network to access these forms. To log into Confluence, you must use your LDAP (SOA Computer Login ID & Password).
All files are in either Word or Adobe PDF format. If you are having difficulty opening them, please email the webmaster.
Forms
For individuals who are not State employees and need to file a claim, please contact the Division of Risk Management at (907) 465-2180 or email RiskManagement@alaska.gov.
You may also download the Notice of Claim form using the link below. Once completed and signed, the form can be submitted via email or mail using the contact information provided on the form.
Volunteer Service Agreement Forms
Report of Occupational Injury or Illness
- https://labor.alaska.gov/wc/forms/07-6101.pdf (Report of Occupational Injury or Illness 07-6101)
- Completed Report of Injury (ROI) forms for State of Alaska employee injuries must be emailed to doa.dop.roi@alaska.gov
- Completed Report of Injury (ROI) forms for AMHS employee injuries must be emailed to doa.dop.roi.amhs@alaska.gov
- Third-Party Claims Administrator:
Penser North America Inc.
PO Box 241148
Anchorage, AK 99524
Toll Free: 1-844-463-2727
Main: (907) 318-2775
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.
- Notice regarding "Long Term Rentals" & "Leased Vehicles" -
The State of Alaska does not provide "automobile physical damage (collision) coverage" for "long term rentals" or "State-leased vehicles." This means Risk Management does not pay for the repairs to those vehicles resulting from any cause, including an accident. The repairs of "long term rentals" or "State-leased vehicles" are the responsibility of the agency assigned to the vehicle. Any rental over 14 days is considered long term.
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)