Arkansas Workers' Compensation Commission

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Arkansas.gov

THIS IS A SAMPLE CLAIM

File Number E000000
Name JOHN J DOE
Address 327 SAMPLE DR

ANY CITY, AR 00000
SSN 000000000
DOB 00/00/0000
Injury Date 00/00/0000
Disability Date 00/00/0000
Post Date 00/00/0000
Date Form1 Received    00/00/0000
Date Formc Received    00/00/0000
Body Part SAMPLE BODY PART
Injury Type SAMPLE INJURY TYPE
Employer SAMPLE EMPLOYER
Carrier SAMPLE CARRIER

 

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

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