ARKANSAS WORKERS’ COMPENSATION COMMISSION Form A R-4 4 324 Spring Street, Little Rock, AR 72201 Mail: P. O. Box 950, Little Rock, AR 72203-0950 501-682-3930 / 1-800-622-4472 Authority: Ark. Code Ann. §11-9-810 Revised: 1-1-2001 REPORT OF COMPENSATION PAID/SUSPENSION OF PAYMENTS “ “ “ “ Update Report Closing Report AWCC File No. Report of Payment Suspension Death/PTD Maximum Liability Carrier Claim No. Employee Name (Last, First, MI) Employe r Name City Carrie r or Sel f-Insur ed Name State Carrier NAIC Number Employer FEIN Number Employee S.S. Number Zip Code Claims Office Location (mailing address) DISABILITY INFORMATION: Date of Injury Last Day Employee Worked Date Employee Able to RTW Did Employee work between date of injury and last day of disability? “ Yes “ No Return - to - Work Date If yes, number of days worked: COMPENSATION INFORMATION: COMPENSATION PAYMENTS MADE: (9) Defense Attorney Fees (1) TTD Weeks Days $ *(10) Other (Compensation Related) (2) TPD Weeks Days (11) Hospital Expenses (3) PPD Weeks Days (12) Medical Expenses (4) Weeks PTD (13) Drugs, Medicine (5) Weeks for Death (14) Funeral Expenses (6) Lump Sum payment (15) Rehabilitation (7) Joint Petition settlement *(16) Other (Expense Related) (8) Claimant Attorney Fees (1 - 16) GRAND TOTAL SUSPENSION OF PAYMENTS OF COMPENSATION Date of Su spension o f Compe nsation: Compensation paid through Reason for Suspension: (date). CERTIFICATION I certify that the foregoing is a complete and accurate report according to the records of the insurer pertaining to payments of compensation and suspensions of payment information. I further certify that a copy of this report or equivalent information has been provided to the em ployee or beneficiaries. Signature Printed or Typewritte n Name Title Date 4 American LegalNet, Inc. www.FormsWorkFlow.com AWCC Form 4 (Report of Paymen t) A Final Re port is due w ithin 30 days o f the last comp ensation pa yment. [Ark. Code Ann . § 11-9-810(b)(1)] Every Form 4 must prov ide the AW CC file num ber. Carriers must list their NAIC number. (National Association of Insurance Commissioners) Employers must list their Federal E mployer Identification numb ers. Form 4 is for all end-of-pa yment repo rts, i.e.: 1. The suspension of benefits; reason for suspension must be given. 2. The closing of a med ical-only case that was accidentally opened by the respondent on Form 1 or by a claimant on Form C. 3. The Fina l Report o f a compe nsable case , detailing all paym ents. Forms 1 , 2, and 3 (or narrative medical report) are required for these cases. 4. Maximum liability being reached in cases involving death or permanent total disability (both the Compensation Section an d the Susp ension of P ayments Sec tion are to be completed). The box for Death/P TD M aximum L iability must be marked. 5. *Other in (10) of the Compensation Information Section includes benefits not listed elsewhere, such as interest and penalties. *Other in (16) wou ld include co urt reporter fees and mile age reimb ursement. Information on Form 4 may be supplied by the Support Services Division. For a specific case, refer to the Office Services Division, which processes Form 4 and closes the case. (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 paym ent; or obtaining or avoiding wo rkers’ compensation coverage or avoiding payment o f the prope r insurance p remium, or who aids an d 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 D isability Trust Fu nd admin istered by the W orkers’ Co mpensatio n Comm ission.” American LegalNet, Inc. www.FormsWorkFlow.com