Alaska Department of Labor &
PO Box 111149
Juneau, AK 99811-1149
FISHERMAN'S REPORT OF INJURY/ILLNESS
& CLAIM FORM
Toll Free: 1-888-520-2766
Telephone: (907) 465-2766
Fax: (907) 465-5345
You must seek treatment within 60 days of injury, and file a claim within one year of first treatment. Complete each item below -
benefits cannot be paid if you do not provide the requested information. Attach a copy of your license/permit card with this form.
1. Name (Last, First, Middle Initial)
3. Date of Birth 4. Social Security No.
5. Street or PO Box Number 6. Home Telephone Number 7. Cell Phone Number
8. City State Zip Code 9. E-mail Address optional
10. Vessel Name 11. Owner of Vessel / Set Net Site 12. Vessel Owner's Telephone 13. Vessel Number
14. Commercial Fishing License or Permit No.:
Date Purchased: Must Attach Copy
15. Date and Time of Injury or Onset of Illness
16. Geographic Location at Time of Injury (Chart Name or Description,
Nearest Landmark, etc.) Be Specific
17. Ill/Injured While
Commercial Fishing Working on Gear/Boat
18. Resource Commercially Fished (ex. Salmon, Cod, Crab, etc.) 19. Gear Type (ex. Troll, Seine, Longline, Pot Gear, etc.)
20. Is the vessel/site insured by a protection & indemnity (P&I) insurance policy?
Yes No Don't Know
If yes, Insurance Company Name:
Have you filed a claim against the vessel owner or the insurance company?
21. At the time of your injury/illness, did you have medical coverage (including private health insurance, Indian health services, veteran's affairs,
Medicare, Medicaid, etc.)?
If yes, name of coverage provider:
22. What is the exact nature of your injury/illness? Be Specific
23. What caused the injury/illness? Be Specific
24. What were you doing at the time of injury? Be Specific
25. Was there a witness?
If yes, witness name:
Witness Address: Telephone Number:
To all health care providers:
You are authorized to provide the Alaska Commercial Fishermen's Fund information concerning any health care advice, testing,
treatment, or supplies provided to me for the injury or illness described above in box 22. This information will be used to evaluate
my entitlement to receive medical benefits from the Fund.
Warning: It is a crime to provide false information for the purpose of defrauding the Alaska Commercial Fishermen's Fund, or any
other person. Penalties include fines and/or imprisonment. In addition, the Fund may deny all benefits if false information
materially related to this claim was provided by the claimant.
Form 07-6125 (Rev 07/2010)