ARKANSAS WORKERS’ COMPENSATION COMMISSION Form AR-V V 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. § 11-9-519(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: 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 ,2 . Signature State of County of SUBSCRIBED AND SWORN TO before me, a Notary Public, on this 2 day of , NOTARY PUBLIC My Commission Expires: v American LegalNet, Inc. www.FormsWorkFlow.com 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 r eached, Form V is furnished to the employee by the respondent carrier or self-insured employer. 2. Form V is furnished to the emplo yee by the Special Funds Division of the Arkansas Workers’ Compensation Comm ission once th e respond ent carrier or self-insured em ployer reac hes its maximu m liability. 3. Notice of the requirement for Form V is made by c ertified mail. 4. An employee's failure to certify permanent total disability within 30 days of receipt of notice shall permit discontinuance of benefits witho ut 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 (1-800-62 2-4472 or 501-6 82-3930). 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 k nowingly om its or concea ls any material information, or who willfully and knowingly employs any device, scheme, or artifice for the purp ose of: obta ining any bene fit or paymen t; defeating or w rongfully increa sing or wron gfully 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.” American LegalNet, Inc. www.FormsWorkFlow.com