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Arkansas Workers' Compensation Commission

Revised Form Instructions
AWCC
(Revised January 1, 2007)

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Code of Abbreviations:

1. ACA: Arkansas Code Annotated
2. AWCC: Arkansas Workers’ Compensation Commission
3. CoP: Change of Physician
4. DEN: Date Employer Notified
5. DoD: Date of Disability
6. DoI: Date of Injury
7. FEIN: Federal Employer Identification Number
8. MO: Medical Only
9. MCO: Managed Care Organization
10. NAIC:  National Association of Insurance Commissioners
11. PTD: Permanent Total Disability
12. TPA: Third Party Administrator

AWCC

AWCC Form 1
Employer's First Report of Injury or Illness

ACA § 11-9-529 allows employers 10 days to report injuries. Those involving more than 7 days of lost time or indemnity payments require Form 1. Also, a Form 1 is required for all controversions, including MO cases. Self-insured employers file Form 1 with the AWCC or their TPA; other employers send it to their insurance representatives.

Employers do not fill in the shaded areas.

On Form 1, employers/carriers must:

1. List in the Occurrence Section the DEN of the injury. The 10 days to report begin either on the DoD or the DEN, whichever date is later.

2. Give the name of the carrier. An agency or TPA should be listed in the Preparer's Section. A carrier can preprint its name and address in the Carrier Section to help clients properly report.

3. Specify the carrier FEIN in the Carrier Section.

4. Type or print in ink. An illegible, incomplete Form 1 will be returned.

Neglect of Form 1: Late employee benefits, exposing employers to fines. Lack of Form 1: Delays in insurance investigation.

AWCC

AWCC Form 2
Employer's Intent to Accept or Controvert Claim

Form 2 is a form to accept a case and report payment or to controvert. It also is used to amend positions taken on an earlier Form 2.

1. The first payment to the employee is due by the 15th day after DEN. ACA § 11-9-802

2. The AWCC is notified upon making the first payment. ACA § 11-9-810

3. A controversion notice is due on or before the 15th day after the DEN. ACA § 11-9-803

4. Therefore, Form 2 in all cases is required by the 15th day from (a) DoD or (b) DEN, whichever date is later.

Include on Form 2:

1. A mark in either the Initial Filing Box or Amended Filing Box.

2. The AWCC File Number (obtained from the electronic notification or E-1) and the insurer's file number.

Keep in mind:

1. Form 2 is NOT interchangeable with the required written response to a Form C filing.

2. If respondents need additional time for investigation, an extension request must be sent before the Form 2 deadline. Using Form 2 to report the respondent needs more time is invalid. If anything is written in the Controversion Section, the AWCC will consider the case controverted.

3. If a case is opened at the AWCC on Form 1 or Form C, a Form 2 is required, even if the case upon investigation is determined to be an MO.

AWCC

AWCC Form 3
Physician's Report

Form 3 or a narrative medical report is required for all compensable cases. If an MO is opened at the AWCC with Form 1 or Form C, a physician's report is helpful to show the employee is released for work.

Form 3 must contain:

1. The AWCC file number

2. A mark in the box for First Report, Progress Report, or Final Report

3. Information on the back in the Temporary Disability Section if Form 3 is a First Report or a Progress Report or

4. Information in the Permanent Disability Section if it is a Final Report.

AWCC

AWCC Form 4
Report of Payment

A Final Report is due within 30 days of the last payment. ACA § 11-9-810(b)(1).

Form 4 must provide the AWCC file number.

Carriers must list their NAIC number.

Employers must list their FEIN.

Form 4 is for all end-of-payment reports, i.e.:

1. The Suspension of Benefits; reason for suspension must be given.

2. The closing of an MO opened by a respondent on Form 1 or a claimant on Form C.

3. The Final Report of an indemnity case, detailing all payments. Forms 1, 2, and 3 (or narrative medical report) are required for these cases.

4. Maximum liability being reached in cases involving death or PTD (both the Compensation Section and the Suspension of Payments Section are completed). The box for Death/PTD Maximum Liability must be marked.

5. Cases with a Lump Sum Payment or a Joint Petition Settlement require Form 4.

*Other on Line (10) of the Compensation Information Section includes benefits not listed elsewhere, such as interest and penalties.

*Other on Line(16) includes court reporter fees and mileage reimbursement.

AWCC

AWCC Form A
Application for Certificate of Non-Coverage

Form A is not used to exclude corporate officers. Their exclusions are handled directly by an agent/carrier.

The Form A application is designed to allow certain individuals to remove themselves from workers’ compensation coverage.

If the answer is yes to any questions on Form A, the application will be rejected unless applicants take the form to their agents, who can provide proof of coverage for the applicant’s employees.

The current processing fee for applications is $50 in the form of a check or money order. Cash should NOT be mailed.

Form A, along with the check and notary statement, should be mailed to the Operations/ Compliance Division, AWCC, P.O. Box 950, Little Rock, AR 72203-0950 or taken to 324 Spring St., Little Rock, AR 72201.

Applications are processed within 10 working days.

AWCC

AWCC Form C
Claim for Compensation

ACA § 11-9-702 allows employees or their dependents to file claims for compensation and sets time limits for those filings.

This is the prescribed form for this action. It is filed directly with the AWCC, usually by claimants or their attorneys.

Care must be taken on Form C:

1. Type or print in ink. Do not use pencil.

2. Employer's business name is needed, not the name of the foreman or supervisor.

3. DoI is essential. If specific date unavailable, list date employee knew of the condition.

4. Employer’s street address is required to allow the AWCC to contact the correct one.

5. Employee's signature is required.

AWCC

AWCC Form D
Death or Permanent Total Disability Case

Rule 099.28 requires submission of Form D to the Death and PTD Trust Fund in January to update all death and PTD cases in the previous calender year. It is filed annually until the fund issues a Certification of Acceptance.

AWCC

AWCC Form H
Health Notice for Managed Care

AWCC Rule 099.33 (Managed Care) requires employers under a Managed Care program to have posted a notice of the MCO or Internal Managed Care System. Form H satisfies the requirements of Rule 099.33.

AWCC

AWCC Form L
Lump Sum Payment

Form L is the employee's request for a lump sum payment and the insurer's response.

The AWCC administrates lump sum payments. ACA § 11-9-804(a)(1)

1. Form L must be signed by both the claimant and an employer's representative before the AWCC will consider a lump sum payment.

2. While a joint petition settlement almost always is approved at an AWCC hearing, a lump sum payment can be approved by mail with the use of Form L.

3. A hearing can be conducted if any disagreements arise.

AWCC

AWCC Form M
Monthly Report on Medical-Only Injury Data

1. Send Form M to the AWCC Operations/Compliance Division after the close of each month and by the 15th day of the next month.

2. Spell out the name of the carrier or self-insured; do not abbreviate.

3. Count calendar days lost rather than work days.

4. Subtract an MO that develops into a compensable case on a subsequent Form M.

5. Report on this form accidents or injuries resulting in disability of seven days or less. Employers that have coverage with carriers are not required to complete this form.

6. Report expenses each month. If medicals are carried into another month, expenses should be included on future M Forms, but the accident should be counted just once.

7. Submit separate reports for each individual carrier or self-insured FEIN number.

TPAs should not complete this form unless designated to do so by the insurer.

Reports with "No Activity" during the period must be completed and so indicated.

The AWCC may fine a carrier or self-insured for failure to submit the monthly report or for a late submission of this form.

FAX reports are acceptable at 501-682-2777.

AWCC

AWCC FORM N
Notice to Employer / Notice to Employee

ACA § 11-9-701: Notice to Employer by Employee

Employees are to complete this form and give it to the employer immediately.

The employer shall not be responsible for disability, medical, or other benefits prior to receipt of the employee’s notice of injury. This notice is the front side of Form N.

The foregoing shall not apply when an employee requires emergency medical treatment outside the employer’s normal business hours.

However, in that event, the employee shall give notice of injury to the employer on the employer’s next regular business day.

ACA §§ 11-9-508, 11-9-514: Notice to Employee by Employer

The employer may select the initial primary care physician from among those associated with a certified MCO.

Employees may request a CoP from the carrier or employer. If the request is denied, employees may send a petition to the Clerk of the AWCC for a one-time-only CoP.

If the employer / insurer fails to give or send a notice to the employee regarding CoP, then those regulations may not apply. This notice is the back side of Form N.

AWCC

AWCC Form P
Poster of Instructions

A posting notice is mandated in ACA §§ 11-9-403, 11-9- 407, and 11-9-514(g) and also AWCC Rule 099.07. AWCC Form P satisfies all requirements.

Form P:

1. Is to be on display in a conspicuous place;

2. Tells employers what to do when an employee is injured;

3. Instructs employees to notify the employer immediately (or no later than the close of the next business day) when injured;

4. Lists the claims office that will handle the case;

5. Gives the claims office telephone number;

6. Announces the expiration date of the insurance policy; and

7. Provides telephone numbers for AWCC legal advisors if either party needs legal counsel.

Employers without Form P may lose the use of Form N as a defense in litigation. Employees disobeying instructions on Form P may delay their benefits or jeopardize the awarding of any benefits in a contested case.

The AWCC furnishes samples, not supplies, of Form P. Carriers are to send their insureds an adequate number, and self-insureds must arrange with a printer for the supply they need. Carriers and employers may enlarge Form P for posting purposes.

AWCC

AWCC Form R
Report of Mediation Conference

The report is placed in the case file and mailed to each party. A written objection to the report by the parties may be filed within 10 days with the Clerk of the Commission, P.O. Box 950, Little Rock, AR 72203-0950.

AWCC

AWCC Form S
Supplemental Report

This form reports any change-in-status, including, but not limited to:

1. The injured employee is back at work and drawing wages;

2. The injured employee is losing time again;

3. The injured employee has died;

Employers should file Form S promptly. It fills in time "gaps" on AWCC Form 4 when the case is closed.

AWCC

AWCC Form V
Verification of Permanent Total Disability

AWCC Form V may be required annually. ACA § 11-9-519(d)

1. Until maximum liability is reached, Form V is furnished to employees by the insurers.

2. Form V is furnished to the employee by the AWCC Special Funds Division once the insurer reaches its maximum liability.

3. Notice of the requirement for Form V is made by certified mail.

4. An employee's failure to certify PTD within 30 days of receipt of notice permits discontinuance of benefits without penalty.

AWCC

AWCC Form W
Wage Statement

1. AWCC Advisory 88-1 requires respondents to file Form W if the claimant receives less than the maximum compensation rate.

2. The average weekly wage of the injured worker shall in no case be computed on less than a full-time workweek in the employment. ACA § 11-9-518(a)(1).

3. AWCC Rule 099.28 requires the submission to the Death and PTD Trust Fund of Form W in all death cases.

AWCC

For questions about the forms, email the Communications Liaison. Current forms are online. Return to the Forms Page and select the “Download Forms” link.

AWCC

State of Arkansas
Workers' Compensation Commission
324 South Spring Street
P.O. 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