Can this form be e-signed?

Yes. Electronic signatures are legally valid under the federal ESIGN Act (15 U.S.C. ch. 96) and UETA in most states, provided intent, consent, attribution, and record retention requirements are met.

What if a field was completed incorrectly?

Correct errors using the insurer's correction procedure or attach a signed amendment. Keep originals and a dated correction log to maintain an audit trail.

Is notarization required?

Notarization is not universally required for claim intake forms; requirements vary by state and specific form. Check Arkansas agency guidance before obtaining notarization.

How long until benefits start?

Timing depends on claim acceptance, medical evidence, and insurer review. Prompt, complete documentation generally reduces processing time but no universal timeframe applies.

What if the worker can't sign?

If the claimant is incapacitated, document why they could not sign and obtain a representative's signature or follow insurer procedures for accepting verbal statements supported by medical records.

Contact the employer's claims representative or the workers' compensation carrier for submission guidance; for legal questions consult an attorney experienced in Arkansas workers' compensation law.

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Arkansas Workers Compensation Form

Arkansas Workers Compensation Form

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ARKANSAS WORKERS' COMPENSATION COMMISSION

Form AR-L

Authority: Ark. Code Ann.

§ 11-9-804

Revised: 1-1-2001

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

CLAIMANT'S LUMP SUM REQUEST/RESPONDENT'S POSITION

AWCC File No.

Carrier Claim No.

Employee Name (Last, First, MI)

Employee SS Number

Employer Name

FEIN No.

City

State

Zip Code

Carrier Or Self-Insured Name

NAIC 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

How much do you want in a lump sum? $

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 . (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

I certify that the foregoing report is true, accurate, and properly states the respondent's position.

Signed:

Date:

L

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).

It must be signed by both the claimant and an employer's representative before the AWCC will consider a lump sum payment.
While a joint petition settlement must be approved at an AWCC hearing, a lump sum payment can be approved by mail.
A hearing can be conducted if any disagreements arise.

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).

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."

What the Arkansas Workers Compensation Form Is and who uses it

The Arkansas Workers Compensation Form is the written claim and reporting documentation used to notify employers, insurers, and the state workers' compensation authority about a work-related injury or occupational illness. It records claimant details, employer information, injury date and description, medical treatment, and wage-loss data so insurers can evaluate benefits. The form supports timely claims handling, benefit determinations, and statutory reporting; employers, claim administrators, attending physicians, and injured workers typically exchange it during intake, medical evaluation, and claim adjudication to establish eligibility and begin benefits processing.

Why accurate completion matters for claims and compliance

Completing the Arkansas Workers Compensation Form accurately preserves benefit rights, speeds insurer review, and reduces disputes. Clear, complete records also help meet employer reporting obligations and provide the documentation needed if the claim proceeds to hearing or review.

Who completes and relies on the Arkansas Workers Compensation Form

Each party has specific fields to complete; coordinated, consistent entries reduce processing delays and disputes.

Employers and HR teams who document incidents and submit initial reports to carriers and the state agency.
Injured workers or their representatives who provide incident details and medical history to support benefit claims.
Insurers, third-party administrators, and claims examiners who evaluate liability, benefits, and medical authorization.

Step-by-step: completing and submitting the form

Follow a consistent sequence to reduce mistakes: collect facts, complete form fields, obtain signatures, and deliver copies to required parties.

01

Gather facts: Collect incident time, witnesses, and initial treatment details before writing the report.
02

Complete fields: Enter names, dates, employer data, and injury description in the specified formats.
03

Obtain signatures: Ensure claimant and authorized employer representative sign and date the form.
04

Submit copies: Provide copies to the insurer, retain an employer file copy, and send any required state filing.

Where the completed Arkansas Workers Compensation Form goes

A completed form is routed to the parties that trigger claims handling and regulatory oversight; follow the listed routing to meet obligations.

Employer record: File a copy in the employer's HR/claims folder for compliance and payroll reconciliation.
Insurance carrier: Send the form to the employer's workers' comp insurer or third-party administrator for claim intake.
State agency: Submit to the state workers' comp commission or designated office if required by Arkansas rules.
Medical provider: Share relevant medical details with treating providers for continuity of care and billing.

Typical digital workflow configuration for online filing

Configure a simple digital workflow to collect, verify, and route completed forms automatically to required parties.

Field	Configuration
Upload document	Accept PDF or DOCX; convert to a locked form for signing.
Assign fields	Place required text, date, and signature fields aligned with printed form layout.
Authentication	Use email verification or SMS code to confirm signer identity.
Routing	Auto-send completed copies to insurer, employer file, and claimant email.

Technical and platform considerations for eSubmitting the form

Secure storage, access controls, and an exportable audit trail are essential for regulatory compliance and later review.

File formats: PDF and DOCX support preserves layout and field alignment during signing.
Audit trail: Capture timestamps, IP, and signer events for evidentiary purposes.
Integrations: Connect with HRIS or claims systems for automated record storage.

Key timing considerations and recommended reporting windows

Timely reporting reduces benefit interruption and potential penalties; follow employer and insurer reporting windows even when state deadlines differ.

Immediate employer notice:

Report the incident to the employer as soon as the worker is able to ensure accurate facts.

Employer to carrier:

Submit the form to the insurer promptly per the employer's policy or carrier contract.

Medical treatment start:

Document the first treatment date and provider to help determine compensability and temporary disability.

Claimant follow-up:

Provide requested medical records quickly to avoid claim delays.

State filings:

File with the state agency when required by Arkansas rules or when disputes arise.

Common mistakes that delay workers' compensation claims

Incomplete dates or vague injury descriptions that force follow-up and slow adjudication.
Using nicknames instead of legal names, which causes identity verification problems with carriers.
Failing to attach initial medical reports or witness statements required to establish compensability.
Not retaining a copy for employer records, leaving no audit trail for later dispute resolution.

Potential consequences of incorrect or late filings

Benefit delays: Incomplete forms can postpone medical or wage-loss payments.

Claim denial risk: Missing facts or late reporting may increase denial likelihood.

Administrative fines: Employers may face regulatory penalties for failing to report.

Evidence gaps: Lost or unsigned pages weaken case credibility.

Legal exposure: Incorrect filings can increase litigation risk and costs.

Privacy breaches: Improper transmission of PHI may trigger HIPAA obligations.

Representative eSignature pricing and capability snapshot for filing forms

A brief vendor comparison showing starting price and common capabilities relevant to filing and eSigning workers' compensation forms.

	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 trial	No	No	Yes, limited	Yes, limited
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Practical tips to complete the form accurately and efficiently

Small process changes prevent errors and speed claim resolution. Implement these proven practices for cleaner submissions.

Standardize field formats

Use fixed formats (MM/DD/YYYY, legal names, full addresses) across all submissions to reduce validation errors and insurer follow-up requests.

Use templates

Maintain an up-to-date, pre-positioned template with validated fields so claim handlers populate only necessary variable data per incident.

Secure sensitive data

Transmit PHI and SSNs only over encrypted channels; limit recipients and log access to comply with HIPAA and privacy policies.

Retain copies

Keep an employer file copy with timestamps and audit trail to support later inquiries or defense of compensability decisions.

Real-world scenarios showing how the form is used

Two concise examples illustrating typical employer and worker interactions when an injury occurs and the form is submitted.

Employer Intake

A warehouse worker reports a back strain after lifting a pallet

Employer documents the incident and attaches a medical slip
The insurer receives the form, authorizes initial treatment, and opens a claim for wage-loss review using attached records and employer payroll data.

Small Contractor Claim

An independent tradesperson reports a hand laceration at a jobsite

The contractor documents the injury and provides witness statements
The insurer evaluates compensability, pays medical bills, and uses the form plus invoices to determine temporary disability benefits.

Frequently asked questions about the Arkansas Workers Compensation Form

Answers to common questions on completion, correction, eSignature use, and who to contact when issues arise.

Need help? Contact support

Can this form be e-signed?
Yes. Electronic signatures are legally valid under the federal ESIGN Act (15 U.S.C. ch. 96) and UETA in most states, provided intent, consent, attribution, and record retention requirements are met.
What if a field was completed incorrectly?
Correct errors using the insurer's correction procedure or attach a signed amendment. Keep originals and a dated correction log to maintain an audit trail.
Is notarization required?
Notarization is not universally required for claim intake forms; requirements vary by state and specific form. Check Arkansas agency guidance before obtaining notarization.
How long until benefits start?
Timing depends on claim acceptance, medical evidence, and insurer review. Prompt, complete documentation generally reduces processing time but no universal timeframe applies.
What if the worker can't sign?
If the claimant is incapacitated, document why they could not sign and obtain a representative's signature or follow insurer procedures for accepting verbal statements supported by medical records.
Where to get help?
Contact the employer's claims representative or the workers' compensation carrier for submission guidance; for legal questions consult an attorney experienced in Arkansas workers' compensation law.

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