A Final Report is due within 30 days of the last payment. ACA § 11-9-810(b)(1).
Form 4 must provide the AWCC file number.
Carriers must list their NAIC number.
Employers must list their FEIN.
Form 4 is for all end-of-payment reports, i.e.:
*Other on Line (10) of the Compensation Information Section includes benefits not listed elsewhere, such as interest and penalties.
*Other on Line(16) includes court reporter fees and mileage reimbursement.
Form A – Application for Certificate of Non-CoverageLast Revision: 01/01/2024
Last Spanish Revision: 01/01/2024
Form A is not used to exclude corporate officers. Their exclusions are handled directly by an agent/carrier.
The Form A application is designed to allow certain individuals to remove themselves from workers’ compensation coverage.
If the answer is yes to any questions on Form A, the application will be rejected unless applicants take the form to their agents, who can provide proof of coverage for the applicant’s employees.
The current processing fee for applications is $50 in the form of a check or money order. Cash should NOT be mailed.
Form A, along with the check and notary statement, should be mailed to the Operations/ Compliance Division, AWCC, P.O. Box 950, Little Rock, AR 72203-0950 or taken to 324 Spring St., Little Rock, AR 72201.
Applications are processed within 10 working days.
For additional details please see the Certificates of Non-Coverage Page.
Form C – Claim for CompensationLast Revision: 06/16/2014
Last Spanish Revision: 08/31/2006
ACA § 11-9-702 allows employees or their dependents to file claims for compensation and sets time limits for those filings.
This is the prescribed form for this action. It is filed directly with the AWCC, usually by claimants or their attorneys.
Care must be taken on Form C:
Form D – Death or Permanent Total Disability CaseLast Revision: 01/01/2011
Rule 099.28 requires submission of Form D to the Death and PTD Trust Fund in January to update all death and PTD cases in the previous calendar year. It is filed annually until the fund issues a Certification of Acceptance.
For questions regarding the filing or completion of this claim form, please contact awcc.formd@arkansas.gov.
Form H – Health Notice for Managed CareLast Revision: 01/01/2001
AWCC Rule 099.33 (Managed Care) requires employers under a Managed Care program to have posted a notice of the MCO or Internal Managed Care System. Form H satisfies the requirements of Rule 099.33.
Form L – Lump Sum PaymentLast Revision: 01/01/2001
Form L is the employee’s request for a lump sum payment and the insurer’s response.
The AWCC administrates lump sum payments. ACA § 11-9-804(a)(1)
For questions regarding the filing or completion of this claim form, please contact AWCC.FormL@arkansas.gov.
Form M – Monthly Report on Medical-Only Injury DataLast Revision: 01/01/2001
TPAs should not complete this form unless designated to do so by the insurer.
Reports with “No Activity” during the period must be completed and so indicated.
The AWCC may fine a carrier or self-insured for failure to submit the monthly report or for a late submission of this form.
FAXED reports are acceptable at 501-682-2777.
For questions regarding the filing or completion of this claim form, please contact AWCC.FormM@arkansas.gov.
Form N – Notice to Employer / Notice to EmployeeLast Revision: 08/01/2006
Last Spanish Revision: 08/01/2006
ACA § 11-9-701: Notice to Employer by Employee
Employees are to complete this form and give it to the employer immediately.
The employer shall not be responsible for disability, medical, or other benefits prior to receipt of the employee’s notice of injury. This notice is the front side of Form N.
The foregoing shall not apply when an employee requires emergency medical treatment outside the employer’s normal business hours.
However, in that event, the employee shall give notice of injury to the employer on the employer’s next regular business day.
ACA §§ 11-9-508, 11-9-514: Notice to Employee by Employer
The employer may select the initial primary care physician from among those associated with a certified MCO.
Employees may request a CoP from the carrier or employer. If the request is denied, employees may send a petition to the Clerk of the AWCC for a one-time-only CoP.
If the employer / insurer fails to give or send a notice to the employee regarding CoP, then those regulations may not apply. This notice is the back side of Form N.