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Arkansas Workers' Compensation Commission

Revised Downloadable Forms
AWCC
(Effective July 1, 2005)

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AWCC

Click on the links to download, view or print the forms.

Claims Adjusting forms
Revised
Form 1 (4-Sided Form) First Report of Injury or Illness 01/01/2002
Form 2 (2-Sided Form) Employer's Intent to Accept or Controvert 01/01/2013
Form 3 (2-Sided Form) Physician's Report 01/01/2001
Form 4 (2-Sided Form) Report of Compensation Paid/Suspension Report 01/01/2011
Form A (3-Sided Form) Instructions on Fee and Notary Statement
Application for Certificate of Non-Coverage (2-Sided)
Required Notary Statement
01/01/2008
Form C (2-Sided Form) Claim for Compensation 08/01/2006
Spanish Form C (2-Sided Form) Claim for Compensation 08/31/2006
Form D (2-Sided Form) Death/PTD Acceptance/Update 01/01/2001
Form H (2-Sided Form) Health Notice for Managed Care 01/01/2001
Form L (2-Sided Form) Lump Sum Request/Respondent's Position 01/01/2001
Form M (2-Sided Form) Monthly Medical-Only Injury Data 01/01/2001
Form N (2-Sided Form) Notice to Employer/Notice to Employee 08/01/2006
Spanish Form N (2-Sided) Notice to Employer/Notice to Employee 08/01/2006
Form O (One-Sided Form) Claim Office / Administrator / Underwriter Designation Form 01/01/2013
Form P (2-Sided Form) Poster of Instructions 04/15/2002
Spanish Form P (2-Sided) Poster of Instructions 10/15/2004
Form R (One-Sided Form) Report of Mediation Conference 01/01/2001
Form S (2-Sided Form) Supplemental Report 01/01/2001
Form V (2-Sided Form) Verification of PTD 01/01/2001
Form W (2-Sided Form) Wage Statement 01/01/2001
Health and Safety Division forms
Revised
Form HS-31-A (2-Sided Form) APSS/FSR Application 01/01/2008
Form HS-31-C (2-Sided Form) Accident Prevention Services Annual Report 07/01/2010
Form HS-31-D (2-Sided Form) Accident Prevention Services Worksheet 07/01/2010
Form HS-31-E (One-Sided Form) List of FSR/APSS 01/01/2001
Form HS-32-A (One-Sided Form) Hazard Survey Report 01/01/2008
Form HS-32-B (One-Sided Form) Health & Safety Plan Cover Sheet 01/01/2008
Form HS-32-C (One-Sided Form) Notification of Potential Data Error 01/01/2001
Form HS-36-A (2-Sided Form) Voluntary Drug-Free Workplace Program Application 07/01/2010
Form HS-36-B (One-Sided Form) Voluntary Drug-Free Workplace Program Annual Insurance Carrier Report 01/01/2008
Self-Insurance Division forms
Revised
Form SI-1 (4-Sided Form) Individual Self-Insurer Application 08/01/2006
Form SI-11 (3-Sided Form) Group Self-Insurance Application 08/01/2006
Form SI-12 (3-Sided Form) Application for Membership in a Group 08/01/2006
Third-Party Administration form
Revised
Form TPA (3-Sided Form) Third-Party Administrator Application / Registration 08/01/2006

AWCCPLEASE NOTEAWCC

The following forms are provided for informational purposes only. These forms are initiated by the commission and sent to the appropriate parties for completion.

Self-Insurance Division forms
Revised
Form SI-7 (One-Sided Form) Loss Summary Data Report 07/01/2006
Form SI-7-A (One-Sided Form) Loss Summary Data Report - Itemized Listing 07/01/2006
Form SI-41 (3-Sided Form) Workers' Compensation Premium Tax Report 01/01/2001
Form SI-41-C (One-Sided Form) Instructions for Completing Premium Tax Report 01/01/2001
Special Funds Division forms
Revised
Form SF-1 (One-Sided Form) Claimant Information Update/Change of Address 01/01/2001
Form SF-2 (One-Sided Form) Guardianship Affidavit (Court - Appointed, Non-Minor) 01/01/2001
Form SF-3 (One-Sided Form) Power of Attorney Notice & Affidavit 01/01/2001
Form SF-4 (One-Sided Form) Surviving Spouse Notice & Affidavit 01/01/2001
Form SF-5 (2-Sided Form) Guardian's Affidavit - Dependent Child(ren) 01/01/2001
Form SF-6 (One-Sided Form) Affidavit for Dependents Other Than Spouse or Child 01/01/2001
Form SF-7 (One-Sided Form) Certification of Acceptance 01/01/2001
Form SF-8 (One-Sided Form) Authorization for Release of Student Information 01/01/2001

 

For questions about any of these forms, email the Communications Liaison

AWCC

State of Arkansas
Workers' Compensation Commission
324 South Spring Street
Post Office Box 950
Little Rock, Arkansas 72203-0950
Telephone 1-501-682-3930 / 1-800-622-4472
Legal Advisor Direct 1-800-250-2511
Arkansas Relay System TDD 1-800-285-1131

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