Incident, Injury & Workers Compensation Claim Forms

All incident and injury forms should be submitted within 24-hours of an incident or within 8-hours if the employee is hospitalized. Forms can be emailed to This email address is being protected from spambots. You need JavaScript enabled to view it. or faxed to (907) 714-2384.

If you have questions or need assistance with the forms, please call the Claims Manager at (907) 714-2353 or the Safety Manager at (907) 714-2354.

• Occupational Injury & Illness Instructions

• Employee Report of Occupational Injury or Illness Form (07-6100)

• Incident Statement Form (Employees & Witnesses)

• Supervisor's Report of Incident or Injury

• Physician's Return to Work Checklist (Emergency Responders)

• Physician's Return to Work Checklist (Occupational Injury)

• Temporary Prescription ID Form

• KPBSD Employees Only: Compensation Options Letter

• Public Loss Claim Form

• Auto Incident Form