Fill and Sign the Form Ar 4 Arkansas Workers Compensation Commission

Form AR -4ARKANSAS 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 Authority: Ark. Code Ann. §11-9-810 Revised: 1-1-2011 REPORT OF COMPENSATION PAID/SUSPENSION OF PAYMENTS “ AMENDED REPORT “ Closing Report “Death/PTD Maximum Liability “ Report of Payment Suspension “Update Report ( additional payments only ) AWCC File No. Carrier Claim No. Employee Name (Last, First, MI) Employee S.S. Number Emplo yer Name CityStateZip Code Car rie r or Self -Insu red N ame Claims Office Location (mailing address) DISABILITY INFORMATION Date of Injury Last Day Employee Worked Date Employee Able to RTWReturn - to - Work Date Total days worked between injury and date able to RTW _____________ COMPENSATION INFORMATION: COMPENSATION PAYMENT S MADE: (9) Defense Attorney Fees (1) TTD Weeks Days $ *(10) Other (Compensatio n Related) (2) TPD Weeks Days (11) Hospital Expenses (3) PPD Weeks Days (12) Medical Expenses (4) Weeks PTD (13) Drugs, Medicine (5) Weeks for Death (14) Funeral Expenses (6) Lump Sum payment (15) Rehabilitation (7) Joint Petition settlement *(16) Other (Expense Related) (8) Claimant Attorney Fees (1 - 16) GRAND TOTAL SUSPENSION OF PAYMENTS OF COMPENSATION Da te of Su spen sion o f Com pen sation: Reason for Suspension: Comp ensation paid through (date). CERTIFICATION I certify that the forego ing is a co mple te and accu rate rep ort ac cord ing to the reco rds o f the in surer p ertaining to payments of compensation and suspe nsions of paym ent information. I further certify that a copy of this r eport or equivalent information has been provid ed to the em ployee o r beneficiaries. Signature Pri nted or Typewr itten Name TitleDate Information on Form 4 may be supplied by the Support Services Division. For a specific case, refer to the Office Services Division, which processes For m 4 and closes the ca se. (1-800-622-4472 or 501-682-3930) Ark. Code Ann . §11-9-106 (a): “Any person or entity who willfully and knowingly makes any material false statement or repres entatio n, who willfully and knowingly omits or conceals any material information, or who willfully and kno win gly employs any device, scheme, or artifice for the purpose of: obtaining any benefit or payment; defeating or wro ngfu lly increa sing o r wro ngfu lly dec reasin g any cla im for benefit or payment; or obtaining or avoiding workers’ compensation coverage or avoiding payment of the proper insurance premium, or who aids and abets fo r any o f said purposes, under this chapter shall be guilty of a Class D felony. Fifty percent (50%) of any criminal fine imposed and collected under .... this section shall be paid and allocated in accordance with applicable law to the Death and Permanent Total Disability Trust Fund administered by the Workers’ Compensation Commission. ” AW CC Form 4 (Rep ort of Pay me nt) A F inal R epo rt is due w ithin 30 days of the las t com pen sation paym ent. [Ark. C ode A nn. § 11 -9-810(b)(1)] Every Form 4 mus t provid e the A W CC file num ber. Form 4 is for all en d-of-p aym ent rep orts, i.e.: 1. The suspension of benefits; reason for suspension must be given. 2 . The closing of a medical-only case that was accidentally opened by the respondent on Form 1 or by a claimant on Form C . 3. The Final R epo rt of a co mpe nsab le case , detailing all pay men ts. Forms 1, 2, and 3 (or narra tive m edica l report) are required for these cases. 4. M axim um lia bili ty being reached in cases involving death or permanent total disability (both the Compensation Section and the Suspension of Payments Section are to be completed). The box for De ath/PT D M axim um L iability must be marked. 5. * Other in (10) of the Compensation Information Section includes benefits not listed elsewhere, such as interest and pen alties. *Other in (16) w ould in clude court re porter fe es an d mile age re imbu rsem ent.