Fill and Sign the Form Ar C Arkansas Workers Compensation

Form AR- 2ARKANSAS 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 2 Authority: Ark. Code Ann. §11- 9-803, -810 Revised 1-1-2013 EMPLOYER’S INTENT TO ACCEPT OR CONTROVERT CLAIM “ Initial Filing “ Amended Filing AWCC F il e No. Car ri er Cla im N o. Em pl oyee Na me (La st , F ir st , M I)Employee SS Number Employer Name Fed . E mpl oyer I.D . No. Address CityStateZip Code Carrie r or Self-Insured Name Claims Office Name, Address, and Phone Is this a medical only claim? “ Y es “ No Is this a PPD-Only Claim? “ Y es “ No COMPENSATION (if not applicable, skip to next section) Da te of First Comp. C heck Da tes Covered by F irst Check Body Part Inju red First D ay o f Disa bility .00 W as D isab ility C ontin uo us D ur ing th e Fir st 8 D ay s? “ Y es “ No Average W eekly Wa ge W kly T TD Com p. Rate (rounded) Da te Indemnity T riggered STATEMENT OF POSITION Date of in ju ry or d ea th : ___ ___ ___ ___ ___ Cit y, St at e of Injury: ____________________ State your position. If controverting, state the grounds therefore: ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ DEATH CASE DATA Li st al l D ep en de nt s b el ow: (If mor e space is needed, at tach suppl emental s heet) If no Depen den ts, check he re : Att ach Death Cert if ica te of Deceas ed Emp loy ee and B irt h Cert if ica tes f or Dep endent Chi ldr en “ Name of dependent Dat e ofRelationship to deceased Weekly benefit amount CERTIFICATION I certify that the foregoing is a complete and accurate report according to the records of the insurer pertai ning 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. Title: Signature Printe d or Typewritten Name Phone: Date If insurer is repres ented by an attorney, that legal representat ive must sign below pursuant to Ark. Code Ann. § 11-9-717 Name and Address of Attorney Signature 2 Questions about a spe ci fi c For m 2, or ge ner al inf orma ti on or ass ist anc e 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 ent it y who wi ll ful ly an d kn owin gly mak es any ma te ri al fal se st at eme nt or representation, who willfully and knowingly omits or conceals any material information, or who willfully and knowingly employs any device, scheme, or a rti fice for the purp ose of: obtaini ng any benefi t or payment ; defeat ing or wrongful ly increa sing or wr ongfu lly decreasing any cl ai m for b en efi t 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 an y c riminal 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. Ark. Code Ann. §11-9-717 : Any perso n or atto rney signin g a clai m, r equ est 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 la w or a good fa ith argum ent for extension, modification or reversal of existing law; and is not interposed for a ny im pro per p ur pose o r for d elay . Vio lato rs of this p rov ision m ay be su bject to san ction s, which may include pay ment of reasonab le expenses incurred by others and reasonable 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 2 (Empl oyer 's Int ent to Acc ept or Contr overt Cla im) A form used to accept a case and report payment or to controvert. AWCC Form 2 also is used to amend positions taken earlier. Help With AWCC Form 2: 1. The first payment to th e employee is due by the 15 th da y after th e emp loyer ha s n oti ce of th e in jur y or death. (Ark. Code Ann. §11-9-802) 2. The AWCC is notified "upon makin g the first payment." (Ark. Code Ann. §11-9-810) 3. A c on t r ove r si on n ot ice is d ue on or be for e t h e 1 5t h da y a ft er n ot i ce of t h e d ea t h or a l l eg ed in ju r y. (Ark. Code Ann. §11-9-803) 4. Th erefore, AWCC Form 2 in al l ca ses i s r equ ir ed by th e 15 th da y from (a) the day of disability or (b) the day the employer is aware of the alleged incident, whichever date is later. Be sure to include on AWCC Form 2: 5. A mark in either the In itial Filin g Box or Amended Filing Box. 6 . The AWCC File Number (obtained from AWCC Form A-110) and your company's file number for this case. Be sure to bear in mind: 7. Form 2 is NOT interchangeable with the required written response to the 15-day letter for Form C. 8. If respondents need additional time for investigation, an extension request must be sent in before the Form 2 deadline. Using Form 2 to report that the respondent n eeds more time is invalid. 9. If a case is opened at the AWCC on Form 1 or Form C , an AWCC Form 2 is requir ed, even if the case upon investigation is determined to be a medical-only claim.