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Arkansas Workers' Compensation Commission

Revised Downloadable Forms
(Effective July 1, 2005)

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All AWCC forms are in Adobe Acrobat PDF format. To view, fill out, or print a copy of these forms requires Adobe Acrobat Reader 5.0 or above. (Preferred method is to save the file and view/fill out/print offline.)

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Claims Adjusting forms
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
Spanish Form A (3-Sided Form) Application for Certificate of Non-Coverage (2-Sided)
Required Notary Statement
Form C (2-Sided Form) Claim for Compensation 06/16/2014
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 06/16/2014
Spanish Form P (2-Sided) Poster of Instructions 06/16/2014
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
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
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
Form TPA (3-Sided Form) Third-Party Administrator Application / Registration 08/01/2006


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
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
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


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

For information or comments regarding this site
contact the AWCC Communications Liaison