Can AR-4 be signed electronically?

Yes; electronic signatures are generally valid under federal ESIGN and state e-signature laws when intent, consent, attribution, and record retention are satisfied. Confirm the Commission or insurer accepts electronic submissions and whether any additional authentication is required.

Who must sign the AR-4?

A responsible employer representative or authorized claims administrator typically signs the form to attest to accuracy. Ensure the signer has authority to attest and that the signature block includes the signer’s printed name and date.

What supporting documents are needed?

Common attachments include initial medical reports, incident narratives, payroll summaries, and witness statements. Insurers may request specific forms; include any documents that substantiate treatment or time lost from work.

How to correct an error on the AR-4?

Submit a corrected AR-4 noting the revision and date. If using an electronic platform, update the record, preserve the prior version in the audit log, and notify insurer and Commission as appropriate.

Is notarization required for AR-4?

Notarization is generally not required for routine workers’ compensation reporting forms. Verify state or carrier instructions when unusual attestations or affidavits are included.

How long should I keep AR-4 records?

Retain AR-4 forms and related medical and payroll records for the life of the claim plus additional years per federal and state retention rules; many organizations keep files for seven years for risk management.

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Arkansas Workers Compensation Commission Form AR-4

Arkansas Workers Compensation Commission Form AR-4

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Form AR-4

Authority:

Ark. Code Ann.

§11-9-810

Revised: 1-1-2011

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

4

REPORT OF COMPENSATION PAID/SUSPENSION OF PAYMENTS

Closing Report

AMENDED REPORT

Report of Payment Suspension

Death/PTD Maximum Liability

Update Report (additional payments only)

AWCC File No.

Carrier Claim No.

Employee Name (Last, First, MI)

Employee S.S. Number

Employer Name

City

State

Zip Code

Carrier or Self-Insured Name

Claims Office Location (mailing address)

DISABILITY INFORMATION

Date of Injury

Last Day Employee Worked

Date Employee Able to RTW

Return - to - Work Date

Total days worked between injury and date able to RTW

COMPENSATION INFORMATION:

COMPENSATION PAYMENTS MADE:

(1) TTD Weeks Days $

(9) Defense Attorney Fees

(2) TPD Weeks Days $

*(10) Other (Compensation Related)

(3) PPD Weeks Days $

(11) Hospital Expenses

(4) Weeks PTD

(12) Medical Expenses

(5) Weeks for Death

(13) Drugs, Medicine

(6) Lump Sum payment

(14) Funeral Expenses

(7) Joint Petition settlement

(15) Rehabilitation

(8) Claimant Attorney Fees

*(16) Other (Expense Related)

(1-16) GRAND TOTAL

SUSPENSION OF PAYMENTS OF COMPENSATION

Date of Suspension of Compensation: Reason for Suspension:

Compensation paid through (date).

CERTIFICATION

I certify that the foregoing is a complete and accurate report according to the records of the insurer pertaining to payments of compensation and suspensions of payment information. I further certify that a copy of this report or equivalent information has been provided to the employee or beneficiaries.

Signature

Printed or Typewritten Name

Title

Date

What the Arkansas Workers Compensation Commission Form AR-4 Is

The Arkansas Workers Compensation Commission Form AR-4 is the employer notice used to report a workplace injury or occupational disease to the Arkansas Workers' Compensation Commission and to the employer's insurance carrier. It documents claimant details, the date and nature of injury, employer and physician information, and initial wage or lost-time data. Employers and insurers use the AR-4 to open a claim file, begin benefits evaluation, and establish a record for medical and indemnity payments. Accurate completion supports timely claims handling and regulatory compliance.

Why Completing Form AR-4 Matters

Filing a correct AR-4 creates a formal claim record, starts medical case management, and protects both employer and worker rights. It helps avoid delays in benefits, supports accurate loss reporting to insurers, and documents the employer’s compliance with Arkansas reporting obligations.

Who Commonly Prepares and Reviews the AR-4

Employers, claims administrators, and treating providers typically interact with the AR-4 during initial claim intake and early case management.

Employers and HR staff who report workplace injuries and supply employer and payroll data.
Third-party administrators and insurance adjusters who manage claims and benefits.
Healthcare providers who complete medical sections to document work-related injury or restrictions.

All parties should ensure data consistency across employer records, medical reports, and insurer systems to reduce processing delays and rework.

Typical Signers and Responsible Parties

Employer HR

An HR representative or safety manager usually completes employer sections, provides payroll and job information, and certifies the employer’s knowledge of the injury. Accuracy prevents misclassification and reduces the risk of penalties or unnecessary disputes.

Claims Rep

A claims adjuster or third-party administrator reviews incoming AR-4 submissions, updates claim status, communicates with medical providers, and ensures the record matches insurer requirements for benefit determination and billing.

Key Parts to Expect on a Professional AR-4

A well-prepared AR-4 organizes claimant, employer, and medical information clearly so reviewers can quickly evaluate compensability and next steps.

Claimant Info

Full legal name, contact, date of birth, social security number when required, and employer relationship details to uniquely identify the injured worker.

Injury Details

Date, time, location, and narrative description of the injury or occupational disease, including body part(s) affected and mechanism of injury.

Employer Data

Employer legal name, address, contact person, SIC/NAICS if requested, payroll basis, carrier name, and policy number for claims routing.

Medical Provider

Name and contact details of the treating physician or facility, initial treatment provided, and whether the claimant was referred for further care.

Wage Information

Earnings, usual work schedule, and average weekly wage or pay rate to support preliminary indemnity calculations when wage replacement may apply.

Signatures

Signature and date fields for the person completing the form plus a designated employer or claims representative to attest to accuracy.

Step-by-Step: Filling Out the AR-4

Complete the form in sequence to ensure each section cross-references correctly and to reduce transcription errors during review.

01

Collect details: Gather claimant, incident, employer, and medical information before starting.
02

Enter employer data: Fill employer and policy fields to route the claim correctly.
03

Describe the injury: Provide factual incident narrative and body parts involved.
04

Sign and submit: Sign, date, and deliver to insurer and the Commission as required.

Configuring an Online AR-4 Workflow

Set up a digital workflow that automates field placement, signer routing, and record retention to speed processing and reduce manual errors.

Field mapping	Pre-place name, date, and wage fields for reuse across claims.
Signer order and roles	Define who signs first and whether witnesses are required.
Authentication method	Choose email link, SMS code, or stronger verifier for identity assurance.
Notifications	Enable automatic alerts for outstanding signatures and status changes.
Retention policy	Configure automatic storage and export to claims systems.

Where to Send the Completed AR-4

After completion, route the AR-4 to all required parties so the claim record is established with both insurer and the Commission without delay.

Employer: Keep a signed copy for your personnel and payroll records.
Insurance Carrier: Submit to the named workers’ compensation insurer for claim intake.
Arkansas WCC: Provide the Commission’s claims intake address or portal copy as required.
Treating Provider: Share the medical sections with the treating clinician as needed.

Digital Signing and Submission Considerations

Use a secure eSignature workflow that supports PDF form fields, audit trails, and appropriate signer authentication for legal validity.

File formats: PDF, DOCX, and fillable forms supported.
Integrations: CRM and document storage integrations available.
Authentication: Email, SMS, and advanced options supported.

Timing Guidance and Typical Deadlines

While Arkansas-specific statutory windows may apply, timely reporting is essential; many insurers expect immediate notice and written reports within a short period after knowledge of injury.

Immediate Notice:

Notify insurer and employee promptly after injury discovery.

Written Report:

Submit AR-4 as soon as initial facts are available to avoid delays.

Medical Reports:

Provide treating provider documentation quickly to support medical payments.

Employer Deadlines:

Follow employer policy and insurer guidance for reporting windows.

Commission Filings:

File with the Commission if the insurer requires or for contested claims.

Key Milestones in the AR-4 Claim Process

These sequential milestones show typical stages from incident to early claim resolution.

01

Incident and Notice

Worker reports injury and employer documents initial information.

02

Employer Report

Employer completes AR-4 and forwards to insurer.

03

Insurer Intake

Carrier opens claim file and assigns adjuster.

04

Initial Decision

Insurer authorizes medical care or requests further investigation.

Common Preparation Errors to Avoid

Incomplete claimant identifiers: missing SSN or DOB delays verification and can trigger requests for additional information from insurer or the Commission.
Vague injury descriptions: overly general narratives force follow-up inquiries and slow medical authorization or claims acceptance decisions.
Wrong policy numbers: incorrect carrier or policy data misroutes the AR-4, causing administrative delays and potential missed benefit deadlines.
Unsigned forms or wrong dates: unsigned or undated submissions are often returned as invalid, increasing processing time and administrative workload.

Consequences of Incorrect or Late AR-4 Filings

Processing Delays: Delayed benefits and longer claims cycles

Penalty Exposure: Fines or administrative penalties may apply

Increased Costs: Higher administrative and legal expenses

Denial Risk: Potential initial denial pending investigation

Record Disputes: Disagreements over the date or circumstances

Reputation Impact: Worker trust and morale can be affected

Supporting Documents and Export Options

Common companion documents and export formats speed review and support downstream claims workflows.

Medical Records

Attach initial treatment notes, diagnostic reports, and work status forms to substantiate care and to support temporary disability determinations.

Payroll Summary

Provide recent payroll or wage statements to enable accurate average weekly wage calculation for benefit estimation.

Incident Report

Include internal incident or safety reports that document witnesses, equipment involved, and immediate corrective actions taken.

Export Formats

Export signed AR-4 copies as PDF/A for long-term archiving and as CSV for claims system ingestion where supported.

Practical Tips for Accurate and Efficient AR-4 Completion

Adopt consistent intake procedures, a prefilled template for employer fields, and a clear signer checklist to minimize errors and rework.

Use a standard intake checklist

Create a checklist that includes claimant identifiers, incident facts, treating provider details, and payroll data so staff collect complete information at first contact.

Validate employer data automatically

Use an electronic template that pre-populates employer name, address, and policy number from a verified company profile to reduce transcription mistakes.

Require signer confirmation

Include a brief attestation field where the signer confirms the accuracy of submitted facts to reduce later disputes about who completed the form.

Keep an audit trail

Retain a signed copy with timestamps, IP or authentication evidence, and change logs to meet potential regulatory and evidentiary needs.

Real-World Examples of Digital Claim Intake

These examples show how organizations streamlined intake and improved turnaround using online forms and secure signing.

Optica Ventures

Optica’s HR team digitized intake to reduce manual entry.

They automated employer fields and routing.
As a result, claims moved to adjusters faster, fewer follow-ups were needed, and staff time spent on paperwork dropped substantially over several months.

Martin Properties

A single-property manager moved to mobile intake after onsite injuries.

Mobile submission captured incident photos and witness data.
This reduced investigation time, provided clearer evidence for claims, and improved tenant and worker confidence in the process.

eSignature Pricing Comparison for AR-4 Workflows

Cost and feature differences across eSignature platforms affect per-user licensing, bulk sending, and compliance capabilities relevant to workers’ compensation form AR-4 processing.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies	Varies	Varies	Varies
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently Asked Questions About Form AR-4

Answers to common questions about completing, signing, and submitting the Arkansas Workers Compensation Commission Form AR-4.

Need help? Contact support

Can AR-4 be signed electronically?
Yes; electronic signatures are generally valid under federal ESIGN and state e-signature laws when intent, consent, attribution, and record retention are satisfied. Confirm the Commission or insurer accepts electronic submissions and whether any additional authentication is required.
Who must sign the AR-4?
A responsible employer representative or authorized claims administrator typically signs the form to attest to accuracy. Ensure the signer has authority to attest and that the signature block includes the signer’s printed name and date.
What supporting documents are needed?
Common attachments include initial medical reports, incident narratives, payroll summaries, and witness statements. Insurers may request specific forms; include any documents that substantiate treatment or time lost from work.
How to correct an error on the AR-4?
Submit a corrected AR-4 noting the revision and date. If using an electronic platform, update the record, preserve the prior version in the audit log, and notify insurer and Commission as appropriate.
Is notarization required for AR-4?
Notarization is generally not required for routine workers’ compensation reporting forms. Verify state or carrier instructions when unusual attestations or affidavits are included.
How long should I keep AR-4 records?
Retain AR-4 forms and related medical and payroll records for the life of the claim plus additional years per federal and state retention rules; many organizations keep files for seven years for risk management.

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