Which form should I use?

Use the Commission's designated claim intake form or cover sheet; employers and insurers often provide a standardized template to collect required fields for Commission filing and carrier processing.

Can this form be signed electronically?

Electronic signatures are generally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states; confirm that the jurisdiction and Commission accept e-signatures for the specific filing type.

Who must sign the form?

The claimant or claimant's representative should sign claimant sections; employer or authorized representative signs employer sections; insurer representatives sign carrier sections when required.

What if information changes after filing?

Submit an amended form or written notice to the Commission and insurer promptly; preserve versions to show chronology and prevent evidentiary disputes.

Is notarization required?

Most workers' compensation forms do not require notarization, but some declarations, releases, or settlement documents may; check Commission rules before obtaining a notary.

How do I appeal a denial?

Follow the Commission's appeal procedures and timelines, which typically involve a written request for hearing and supporting evidence; missing deadlines can forfeit appeal rights.

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Arkansas Workers' Compensation Commission Form

Arkansas Workers' Compensation Commission Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Form AR-V

Authority. Ark. Code
Ann. § 11-9-519(d)
Revised 1-1-2001

ARKANSAS 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

V

VERIFICATION OF PERMANENT TOTAL DISABILITY

RETURN TO:

Insurance Carrier/Self-Insured or AWCC Special Funds Division

Name of

Employee:

Address:

City

State

Zip

I, do hereby certify and affirm that I am permanently and totally disabled due to my work-related condition. Also, I am not presently, nor have I been, gainfully employed since I became permanently and totally disabled.

Dated this day of

Signature

State of

County of

SUBSCRIBED AND SWORN TO before me, a Notary Public, on this day of

My Commission Expires:

NOTARY PUBLIC

V

AWCC Form V

(Verification of Permanent Total Disability)

AWCC Form V may be required annually pursuant to Ark. Code Ann. §11-9-519(d).

Until maximum liability has been reached, Form V is furnished to the employee by the respondent carrier or self-insured employer.
Form V is furnished to the employee by the Special Funds Division of the Arkansas Workers' Compensation Commission once the respondent carrier or self-insured employer reaches its maximum liability.
Notice of the requirement for Form V is made by certified mail.
An employee's failure to certify permanent total disability within 30 days of receipt of notice shall permit discontinuance of benefits without penalty.

Questions about Form V should be directed to the insurance representative sending the form
to the claimant. General information is available from the AWCC Special Funds Division or
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 Commission Form Is

The Arkansas Workers' Compensation Commission Form is the standard document used to report workplace injuries, illnesses, and related claims to the Arkansas Workers' Compensation Commission and to notify employers and insurers about a compensable event. It collects claimant identification, employer and insurer details, date and description of injury, medical treatment received, and return-to-work information. The form creates an official record for claim intake, triage, and adjudication and supports timelines for benefits, medical care coordination, and potential hearings before the Commission.

Why Accurate Filing Matters

Completing the form correctly protects an injured worker's access to medical and wage-loss benefits, preserves employer and carrier rights, and creates a clear administrative record for any Commission review or hearing.

Who Completes and Uses This Form

Several parties rely on the form to start or manage a workers' compensation claim; each has distinct responsibilities when completing or receiving it.

Employer or HR representative: prepares employer sections, documents notice and job details for the claim file.
Injured employee (claimant): provides personal, injury, and treatment details needed for benefit eligibility.
Insurance carrier or claims adjuster: records coverage, reserves, and next steps for medical and indemnity payments.

Correct completion ensures smooth routing to carrier and the Arkansas Workers' Compensation Commission and reduces the risk of disputes or processing delays.

Primary Signers and Record Holders

Employer Representative

A human resources or safety officer typically completes employer sections, certifies work details and wages, and forwards the form to the insurer and Commission as required.

Claims Adjuster

An insurance claims adjuster or third-party administrator reviews the submission, records file number and reserves, communicates with medical providers, and manages Commission filings and hearings.

Step-by-Step: Completing the Form

Follow these sequential steps to prepare a complete, Commission-ready submission.

01

Gather Records: Collect ID, payroll, incident and medical notes.
02

Complete Sections: Fill claimant, employer, and injury fields fully.
03

Review: Confirm dates, names, and employer identifiers.
04

Submit: Send to insurer and file with the Commission per rules.

How the Form Moves Through the System

This outlines the typical routing steps after the form is completed by the employer or claimant.

Employer Intake: Employer records incident and forwards to insurer.
Insurer Review: Adjuster accepts, investigates, and sets reserves.
Commission Filing: Commission receives form for docketing or case opening.
Adjudication: Claim is assigned for mediation, hearing, or resolution.

Recommended Digital Workflow Settings

Configure e-submission to ensure captured data, signer verification, and automated routing to insurer and Commission.

Field	Configuration
Authentication Method	Email link or SMS code for signer verification
Required Fields	Claimant name, injury date, employer FEIN required
Conditional Fields	Show medical provider fields when medical care indicated
Notifications	Auto-notify employer, adjuster, and claimant on completion

Technical Requirements for eSubmission

Use a platform that supports secure PDFs, audit trails, and common integrations to streamline filing and records retention.

File Formats: PDF, DOCX accepted
Integrations: Salesforce, NetSuite, Microsoft 365
Authentication: Email, SMS, or stronger methods

Proper platform choices reduce manual entry, preserve evidentiary audit trails, and align submissions with Commission and insurer processes without changing legal responsibilities.

Essential Components of a Professional Submission

A complete form collects claimant, employer, incident, and medical data and includes clear signatures and attachments to support the claim.

Header Information

Includes case or claim number, employer legal name, and insurer contact details so the file is immediately routable and identifiable.

Claimant Details

Full legal name, date of birth, contact information, and U.S. taxpayer ID or last four digits to confirm identity and eligibility.

Incident Summary

Date, time, location, and concise narrative of the event describing how the injury occurred and tasks being performed.

Medical Treatment

Name of treating provider, dates of visits, and summary of diagnoses and recommended work restrictions or follow-up care.

Wage and Job Data

Job title, pay rate, typical hours, and last date worked to calculate temporary total or partial disability benefits if applicable.

Signature Block

Signed and dated attestations from claimant or employer with printed names and job titles to validate the submission.

Attachments and Export Options to Include

Attach supporting documentation and keep export copies in standard formats for insurer and Commission review.

Medical Records

Attach initial ER reports, physician notes, and test results to substantiate treatment and causal relationship to workplace activity.

Photographs

Include images of the injury scene or hazard to illustrate mechanism and support investigation findings.

Payroll Records

Provide wage statements or payroll summaries to verify pre-injury earnings for indemnity calculations.

Export Formats

Save signed files as PDF/A or standard PDF for long-term retention and interchange with Commission systems.

Timing Considerations and Recommended Deadlines

Timely reporting preserves benefits and legal rights. Specific filing windows vary by jurisdiction and the Commission; act promptly after an injury.

Immediate Notice to Employer:

Report the incident to your employer as soon as practicable to start benefits processing.

Employer to Insurer:

Employers should notify their carrier per policy terms and state rules without undue delay.

File with Commission:

Where required, submit to the Commission according to its claim intake rules; check Commission guidance for exact timing.

Seek Medical Care:

Obtain treatment promptly; delays can complicate causal proof and benefit entitlement.

Preserve Evidence:

Collect witness statements, photos, and records immediately while details remain fresh.

Key Milestones from Injury to Resolution

A high-level sequence of milestones helps track progress and maintain required records during a claim lifecycle.

01

Incident Occurs

Document event details and notify employer promptly.

02

Employer Report

Employer records incident and informs insurer.

03

Medical Evaluation

Provider documents injury and work restrictions.

04

Claim Determination

Insurer or Commission adjudicates compensability and benefits.

Common Preparation Errors to Avoid

Entering incorrect injury dates or inconsistent timelines that create disputes over causation and eligibility.
Omitting treating provider details or medical documentation, which delays care authorization and billing.
Using informal descriptions instead of clear incident narratives that accurately describe mechanism and task performed.
Failing to sign or date the form, causing administrative rejection or requests for resubmission.

Consequences of Inaccurate or Late Filings

Claim Denial: Benefits delayed or denied

Civil Liability: Potential employer or insurer disputes

Administrative Fines: Penalties under state rules

Privacy Breach: Improper handling risks HIPAA violations

Evidence Loss: Delayed collection weakens proof

Appeal Complexity: Errors complicate later hearings

eSignature Vendor Comparison for Commission Filings

Key vendor pricing and capability differences relevant to high-volume or regulated workers' compensation workflows are shown below without date references.

	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, no credit card	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	No cap	No cap	No cap

Frequently Asked Questions About the Form

Answers to common questions about completing, signing, and filing the Arkansas Workers' Compensation Commission Form.

Need help? Contact support

Which form should I use?
Use the Commission's designated claim intake form or cover sheet; employers and insurers often provide a standardized template to collect required fields for Commission filing and carrier processing.
Can this form be signed electronically?
Electronic signatures are generally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states; confirm that the jurisdiction and Commission accept e-signatures for the specific filing type.
Who must sign the form?
The claimant or claimant's representative should sign claimant sections; employer or authorized representative signs employer sections; insurer representatives sign carrier sections when required.
What if information changes after filing?
Submit an amended form or written notice to the Commission and insurer promptly; preserve versions to show chronology and prevent evidentiary disputes.
Is notarization required?
Most workers' compensation forms do not require notarization, but some declarations, releases, or settlement documents may; check Commission rules before obtaining a notary.
How do I appeal a denial?
Follow the Commission's appeal procedures and timelines, which typically involve a written request for hearing and supporting evidence; missing deadlines can forfeit appeal rights.

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