Fill and Sign the Form Ar N Arkansas Workers Compensation

Form AR-LARKANSAS 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 L Authority: Ark. Code Ann. § 11-9-804 Revised: 1-1-2001 CLAIMANT’S LUMP SUM REQUEST/RESPONDENT’S POSITION AWCC File No.Carrier Claim No.Employee Name (Last, First, MI)Employee SS Number Employer NameFEIN No.CityStateZip Code Carrier Or Self-Insured NameNAIC No.Claims Office Address CLAIMANT’S INFORMATION Are you presently working? “ Yes “ No If yes, name of employer What is your weekly salary? Any other sources of income? “ Yes “ No Amount per week? I agree that the lump sum payment be computed upon the basis of % permanent partial disability to (body part or whole body) How much do you want in a lump sum? $ (amount) Give complete, specific and detailed reason for lump sum and use of money: I understand that any lump sum payment received will be discounted at 10% per year. Further, I specifically waive a formal hearing before the Arkansas Workers’ Compensation Commission in connection with this request. Signature: Date: RESPONDENT’S INFORMATION Respondent objects to the claimant’s request for a lump sum settlement: “ Yes “ No. If respondent does not object, complete the questions below. If you do object, sign below and leave the remainder unanswered. Does respondent waive a hearing? “Yes “ No. Respondent agrees that the claimant’s healing period ended on (date), and the claimant has a % permanent partial disability to the (body part). (Please attach physician’s report indicating end of healing period and PPD rating.) Weekly PPD Rate $ . PPD Benefits have been paid beginning (date) through (date) for a total $ . Respondent agrees that the number of weeks of compensation yet due for PPD are (weeks). I certify that the foregoing report is true, accurate, and properly states the respondent’s position. Signed: Date: L Help with Form L and lump sum payments is available from the Legal Advisor Division (1-800-250-2511 or 501-682-3930) General information is available from the Support Services Division (1-800-622-4472 or 501-682-3930).AWCC Form L (Lump Sum Payment) Form L is the employee's request for a lump sum payment and the respondent's position. Using Form L aids the AWCC in the administration of its functions under Ark. Code Ann. §11-9- 804(a)(1). 1. It must be signed by both the claimant and an employer's representative before the AWCC will consider a lump sum payment. 2. While a joint petition settlement must be approved at an AWCC hearing, a lump sum payment can be approved by mail. 3. A hearing can be conducted if any disagreements arise. 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. 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.”