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Arkansas Workers' Compensation Form

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ARKANSAS WORKERS’ COMPENSATION COMMISSION
EMPLOYER’S INTENT TO ACCEPT OR CONTROVERT CLAIM

AWCC File No.

Carrier Claim No.

Employee Name (Last, First, MI)

Employee SS Number

Employer Name

Fed. Employer I.D. No.

Address

City

State

Zip Code

Carrier or Self-Insured Name

Claims Office Name, Address, and Phone

Is this a medical only claim?

Is this a PPD-Only Claim?

COMPENSATION

(if not applicable, skip to next section)

Date of First Comp. Check

Dates Covered by First Check

Body Part Injured

First Day of Disability

Average Weekly Wage

Wkly TTD Comp. Rate (rounded)

Was Disability Continuous During the First 8 Days?

Date Indemnity Triggered

STATEMENT OF POSITION

Date of injury or death

City, State of Injury

State your position. If controverting, state the grounds therefore:

DEATH CASE DATA

List all Dependents below: (If more space is needed, attach supplemental sheet)

Attach Death Certificate of Deceased Employee and Birth Certificates for Dependent Children

Name of dependent

Date of

Relationship to deceased

Weekly benefit amount

CERTIFICATION

I certify that the foregoing is a complete and accurate report according to the records of the insurer pertaining to first payment, controversion and beneficiary 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

Phone

Date

If insurer is represented by an attorney, that legal representative must sign below pursuant to Ark. Code Ann. § 11-9-717

Name and Address of Attorney

Signature

Questions about a specific Form 2, or general information or assistance on completing or filing a Form 2, may be directed to the AWCC Operations and Compliance Division, which processes this form (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 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 of 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.

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.

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What the Arkansas Workers' Compensation Form Is

The Arkansas Workers' Compensation Form documents an on-the-job injury or occupational disease and initiates benefits and administrative handling under Arkansas law. It captures claimant identity, employer details, injury date and description, wage and job information, treating provider data, and initial medical treatment. Employers, insurers, and claims administrators use the form to determine eligibility, calculate benefits, and record the event for regulatory reporting. While carriers often have proprietary versions, Arkansas-specific forms must conform to the Arkansas Workers' Compensation Commission rules and insurer reporting requirements to avoid processing delays or benefit disputes.

Why a Correct Form Matters for Claims

A complete, accurate Arkansas Workers' Compensation Form preserves claim rights, speeds benefit delivery, and reduces disputes. Properly documented injuries support medical care authorization, wage-loss calculations, and regulatory compliance while creating an auditable record for the employer, insurer, and claims examiner.

Why a Correct Form Matters for Claims

Who Completes and Uses This Form

The form is completed and relied on by several parties during a workers' compensation claim lifecycle.

  • Employers and HR teams that record incident details and transmit the report to their carrier or claims administrator.
  • Injured employees or claimants who confirm injury facts and provide medical provider and wage information.
  • Claims examiners and insurers who evaluate compensability, process benefits, and coordinate care and payments.

Each party's timely and accurate inputs reduce processing time and the likelihood of administrative denials or audits.

Step-by-Step: Completing the Arkansas Workers' Compensation Form

Follow these sequential steps to prepare a complete, defensible report that supports benefits and regulatory requirements.

  • 01
    1. Gather details: Collect claimant, employer, and injury facts before starting the form.
  • 02
    2. Describe injury: Provide specific body parts, mechanism, and exact date/time of incident.
  • 03
    3. Attach documents: Include initial medical reports, payroll records, and witness statements where available.
  • 04
    4. Submit promptly: Send to insurer and retain a copy for regulatory or audit needs.

How to Configure an Online Workflow for This Form

Set up a digital template that enforces required fields and routes submissions to the insurer and your claims team.

Field validation rules Require key fields such as injury date and claimant name.
Authentication method Choose email link, SMS code, or stronger signer verification.
Conditional fields Show additional fields when hospitalization or lost time applies.
Automatic notifications Notify HR, safety, and insurer upon submission.
Template saving Save a reusable template to ensure consistency.

Where to Send or File the Completed Form

Follow your insurer contract and Arkansas Commission guidance for routing; keep copies for internal records.

  • Primary carrier: Submit the report to your workers' comp insurance carrier or third-party administrator.
  • Arkansas Commission: File with the Arkansas Workers' Compensation Commission when required by regulation or contested claims.
  • Internal HR file: Retain a copy in the employee's secure personnel or safety file.
  • Medical provider: Share relevant medical authorization pages with treating clinicians.

Digital Signing and File Format Considerations

Use e-signature tools and storage formats that preserve audit trails and meet legal requirements for electronic records.

  • Accepted formats: PDF and DOCX preserve fidelity for signatures and attachments.
  • Integrations: Connectors to HRIS, claims systems, and cloud storage improve workflow.
  • Authentication: Use email, SMS, or stronger verification per risk level.

Ensure the chosen platform supports ESIGN/UETA, provides a tamper-evident audit trail, and can store signed records for the required retention period.

Timing Expectations and Typical Reporting Windows

Timely reporting reduces benefit delays and preserves rights; follow your carrier and Arkansas Commission guidance for exact windows.

Immediate employer report:

Report injury to employer as soon as practicable after occurrence.

Insurer notification:

Notify your insurer per policy — many require prompt notice to investigate.

Medical treatment:

Seek prompt medical evaluation so treatment can be authorized.

Commission filings:

File formal petitions or notices with the Commission when disputes arise.

Record retention:

Keep submission copies until legal retention obligations expire.

Key Milestones from Injury to Claim Resolution

This milestone timeline outlines typical stages you can expect as a claim progresses from report to closure.

01

Injury Report Filed

Claim initiation and first-notice-of-injury submission to insurer.

02

Initial Investigation

Insurer reviews facts, medical records, and compensability factors.

03

Benefits Determination

Insurer authorizes treatment or begins indemnity payments.

04

Closure or Dispute

Claim closes after settlement or proceeds to Commission hearing if contested.

Common Pitfalls When Preparing the Form

  • Incomplete medical details that force follow-up and delay treatment authorizations.
  • Incorrect wage or employment dates that cause errors in benefit rate calculations.
  • Missing witness names or contact information that hinders incident verification.
  • Late submission to the insurer that can complicate coverage or benefits processing.

Consequences of Errors or Delays

Claim denial: Possible denial of benefits.
Payment delays: Indemnity and medical payment delays.
Administrative fines: Potential fines per insurer or regulator.
Reopened claims: Later disputes can reopen exposures.
Tax implications: Incorrect wage reporting affects payroll tax.
Audit exposure: Increases chance of regulatory audit.

eSignature Platform Pricing and Feature Snapshot Relevant to Forms

Compare basic pricing and capability markers for common eSignature vendors; signNow is listed first as the initial column for comparison consistency.

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

Security and Compliance Considerations

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest
HIPAA: BAA required for protected health information
ESIGN / UETA: Accepts electronic signatures per federal and state law
Audit Trail: Timestamped events and signer attribution
Certifications: SOC 2 Type II, ISO 27001 available
Accessibility: WCAG 2.0 Level AA support

Typical Signatories and Authorized Approvers

HR Manager

Human resources or safety managers typically complete and attest to the employer portion of the form, verify payroll and job details, and authorize submission to the insurer. They must ensure records are retained and that the form matches payroll and timekeeping data to prevent discrepancies during claim adjudication.

Claims Adjuster

Claims administrators and adjusters review the completed form, request additional documentation, and authorize benefit payments or denial notices. They rely on medical records, wage documentation, and witness statements to determine compensability and to set reserves for ongoing case management.

Frequently Asked Questions and Troubleshooting

Answers to common questions about completing, signing, and submitting the Arkansas Workers' Compensation Form to help avoid processing delays.


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