Fill and Sign the Forms Arkansas Workers Compensation Commission

Form AR-VARKANSAS WORKERS’ COMPENSATION COMMISSION 324 Spring Street, Little Rock, AR 72201 Mail: P. O. Box 950, Little Rock, AR 72203-0950 501-682-3930 / 1-800-622-4472V Authority: Ark. Code Ann. § 11-9-519(d) Revised 1-1-2001 VERIFICATION OF PERMANENT TOTAL DISABILITY RETURN TO: “ Insurance Carrier/Self-Insured or“ AWCC Special Funds Division Name of Employee: Address: CityStateZip 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 , 2 . Signature State of County of SUBSCRIBED AND SWORN TO before me, a Notary Public, on this day of , 2 NOTARY PUBLIC My Commission Expires: v 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.”AWCC Form V (Verification of Permanent Total Disability) AWCC Form V may be required annually pursuant to Ark. Code Ann. §11-9-519(d). 1.Until maximum liability has been reached, Form V is furnished to the employee by the respondent carrier or self-insured employer. 2.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. 3.Notice of the requirement for Form V is made by certified mail. 4.An employee's failure to certify permanent total disability within 30 days of receipt of notice shall permit discontinuance of benefits without penalty.