Fill and Sign the Claim for Compensation Ar Cpdf Fpdf DOC Docxarkansas Form

Form AR-C ARKANSAS WORKERS’ COMPENSATION COMMISSION 324 Spring Street, Little Rock, AR 72201 Mail: P. O. Box 950, Little Rock, AR 72203-0950 501-682-3930 / 1-800-622-4472 1-800-622-4472 (Little Rock Office) 1-800-852-5376 (Springdale Office) C Au tho rity: A rk. C od e A nn . § 11-9-702 Revised: 1-1-2001 Updated: 6-16-14 CLAIM FOR COMPENSATION EMPLOYEE INFORMATION (Please Print in Ink) Employee’s Last Name First NameM. I.Social Security Number Da te of B irth(A rea C ode ) H om e Ph one No . Street Address or P.O. Box CityStateZip Code Child Sup port O bligation : “ Cur rent “ Past Due Payable to: EM PL OY ER INF OR M AT ION (Please Print) Emp loyer’s Name (na me und er which d oing business) (Area Code) Employer’s Telephone No. Employer’s Street Address Em ploye r’s CityStateZip Code AC CID EN T IN FO RM AT ION (Please Print) Employer’s Workers’ Compensation Insurance Carrier ( if known) Place of Accident (City, State)Date of Accident Brie fly de scrib e the cau se o f inju ry an d the part o f bo dy in jured : \ \ ________________________________________________________________________\ _________________________________________________________________ ________________________________________________________________________\ ___________________________________________________________________ ________________________________________________________________________\ _______________________________________________________________ \ \ \ CL AIM INF OR M AT ION (Please Print) If this claim is for initial benefits (no benefits, either medical or indemnity, have been received)\ , what compensation bene fits are you claiming? “ Temporary Total Disability “ Temporary Partial Disability “ Permanent Partial Disability “ Permanent Total Disability “ Rehabilitation “ Attorney Fees “ Medical Expenses “ Other (Explain): If this claim is for additional benefits, what specific benefits are you claiming? “ Additional Temporary Total “ Additional Temporary Partial Disability “ Additional Permanent Partial “ Additional Medical Expenses “ Rehabilitation “ Attorney Fees “ Other (Explain): If employee is deceased and claim is for death benefits, list name and address of all persons claiming death benefits: List person or entity (with address, phone number) which has paid benefits under a group health, disability or loss of income policy for the injury reported on this form: I hereby authorize any hospital, physician, psychotherapist or practitioner of the healing arts to furnish the bearer any information, including, but not limited to, copies of medical records concerning my past, present or f utu re p hy sica l, me nta l or e mo tion al co nd ition . I hereby waive my physician- and psychotherapist-patient privilege. A photostatic copy of th is auth oriza tion s hall b e as e ffectiv e an d va lid as th e orig inal. Da te: Signature: \ \ If claimant is represented by an attorney, that legal represent ative must sign below pursuant to Ark. Code Ann. §11-9-717. Nam e and Ad dress o f Attorn ey \ Sig nature C Questions on a specific Form C m ay be answered by the Legal Advisor Division (1-800-250-2511 or 501- 682-39 30). General information is available from the Support Services Division (1-800-622-4472 or 501- 682-39 30). Ark. Code Ann. §11-9-115 require s app licants fo r wo rkers' co mpe nsatio n ben efits to state if child su ppo rt paym ents are due, to whom, and if payments are current or past due. Ark. Code Ann. §11-9-717: Any person or attorney signing a claim, request for benefits, controversion of benefits, request for hearing or other paper of a party, certifies the action is taken after reasonable inquiry; is well grounded in fact; is warranted by existing law or a good faith argument for extension, modification or reversal of existing law; and is not interposed for any improper purpose or for delay. Violators of this provision may be subject to sanctions, which may include payment of reasonable e xpenses incurred by others and reaso nab le attorney fees for responding to the claim, request or motion, or for failure to appear at a hearing, deposition or other scheduled matter. AWCC Form C (Claim for Compensation) Ark. Code Ann. § 11-9-702 allows employees or their dependents to file claims for compensation and sets time limits for those filings. This is the AW CC's prescribed form for this action. It is filed directly with the AW CC, usually by claimants or their attorneys. Care must be taken on Form C: 1. Typ e or prin t in ink. D o not use p encil. 2. Inform ation m ust be com plete. 3. Em ploye r's busine ss nam e is nee ded , not the nam e of the forem an or s upe rvisor. 4. Da te of injury is essential. If specific date unavailable, as in the case of diseases, list date employee knew of the condition. 5. Street address o f employ er must be g iven to allow the AW CC to contact the correc t employe r. 6. Employee's signature at bottom is required. Ark. Code Ann . §11-9-10 6(a): Any person or entity who willfully and knowingly makes any material false statement or representation, who willfully and knowingly omits or conceals any material information, or who willfully and knowingly employs any device, scheme, or artifice for the purpose o f: obtaining any benefit or payment; defeating or wrongfully increasing or wrongfully decreasing any claim for benefit or payment; or obtaining or avoiding workers’ compensation coverage or avoiding payment of the proper insurance premium, or who aids and abets for any of said purposes, under this chapter shall be guilty of a Class D felony. Fifty percent (50%) of any criminal fine imposed and collected und er .... this sec tion sh all be p aid an d alloc ated in acco rdan ce w ith app licable la w to the D eath and Permanent Total Disability Trust Fund administered by the Workers’ Compensation Commission.