Fill and Sign the Form Ar W

AWCC No.Carrier NAIC No.:Carrier or Self-Insured Name:Employer FEIN No.:Employer Name:Employee S.S.No.:Employee Name:Carrier Claim No.INSTRUCTIONS FOR COMPLETING WAGE STATEMENT (To be completed only if claimant receives less than maximum benefits) In completing the Wage Statement, in week one give information for the week prior to the injury and follow with preceding weeks. Days and hours of straight time work should be given in all cases. Explanation of time lost by employee: wForm AR-WARKANSAS WORKERS’ COMPENSATION COMMISSION 324 Spring Street, Little Rock, AR 72201 Mail: P. O. Box 950, Little Rock, AR 72203-0950 501-682-3930 / 1-800-622-4472W Authority: Ark. Code Ann. §11-9-518 Revised: 1-1-2001 WAGE STATEMENT IMMEDIATELY PRECEDING INJURY DATE Weeks Straight Time WorkedWages Paid For Straight TimeOvertime Hours WorkedWages Paid for Overtine DaysHoursDaysHours 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 Total Information on Form W is available from the Office Services Section. General Information is available from the Support Services Division. (1-800-622-4472 or 501-682-3930)AWCC Form W (Wage Statement) 1. The AWCC Advisory 88-1 requires respondents to file Form W (with the AWCC file number for the case, obtained from AWCC Form A-110) if the claimant receives less than the maximum compensation rate. 2. The average weekly wage of the injured worker shall "[I]n no case...be computed on less than a full-time workweek in the employment." [Ark . Code Ann. § 11-9-518(a)(1)] 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.”