| Title |
Last Updated |
| Power Of Attorney Notice And Affidavit |
August 3, 2015 |
| Workers Compensation Instructions To Employers And Employees |
August 3, 2015 |
| Notice Of Claimant Information Update Change Of Address |
August 3, 2015 |
| Surving Spouse Notice And Affidavit |
August 3, 2015 |
| Certification Of Acceptance |
August 3, 2015 |
| Claim For Compensation |
August 3, 2015 |
| Guardians Affidavit-Dependent Children |
August 3, 2015 |
| Guardianship Affidavit Court-Appointed Non-Minor |
August 3, 2015 |
| Affidavit For Dependents Other Than Spouse Or Child |
August 3, 2015 |
| Authorization For Release Of Student Information |
August 3, 2015 |
| Claim Office Administrator Underwriter Designation Form |
December 12, 2013 |
| Employers Intent To Accept Or Controvert Claim |
December 12, 2013 |
| Employees Notice Of Injury |
November 2, 2012 |
| Death And Permanent Total Disability Acceptance Update |
November 2, 2012 |
| Claimants Lump Sum Request Respondents Position |
November 2, 2012 |
| Wage Statement Immediately Preceding Injury Date |
November 2, 2012 |
| Verification Of Permanent Total Disability |
November 2, 2012 |
| Report Of Compensation Paid Suspension Of Payments |
November 2, 2012 |
| Physicians Report |
November 2, 2012 |
| Health Care Notice For Employees Under Managed Care |
November 2, 2012 |
| Monthly Report On Medical Only Injury Data |
November 2, 2012 |
| Occupational Safety And Health Work Experience |
November 2, 2012 |
| Voluntary Drug-Free Workplace Programs VDFWP Annual Insurance Carrier Report |
November 2, 2012 |
| Health And Safety Plan Coversheet |
November 2, 2012 |
| Evaluation Of Accident Prevention Services Of Arkansas Workers Comp Insurance Carriers |
November 2, 2012 |
| Claim Office Administrator Underwriter Designation Form |
November 2, 2012 |
| Supplemental Report |
November 2, 2012 |
| Report Of Mediation Conference |
November 2, 2012 |
| Notification Of Potential Data Error |
November 2, 2012 |
| Hazard Survey Report |
November 2, 2012 |
| First Report Of Injury Or Illness |
November 2, 2012 |
| Claim For Compensation |
November 2, 2012 |
| Accident Prevention Services Worksheet |
November 2, 2012 |
| Accident Prevention Services Annual Report |
November 2, 2012 |
| Application For Voluntary Drug-Free Workplace Program |
December 1, 2010 |
| Workers Compensation Instructions To Employers And Employees |
September 4, 2008 |
| Application For Certificate Of Non-Coverage |
April 1, 2008 |
| Third Party Administrator Application Or Registration |
November 28, 2006 |
| Surving Spouse Notice And Affidavit |
October 11, 2006 |
| Power Of Attorney Notice And Affidavit |
October 11, 2006 |
| Notice Of Claimant Information Update Change Of Address |
October 11, 2006 |
| Guardianship Affidavit Court-Appointed Non-Minor |
October 11, 2006 |
| Guardians Affidavit-Dependent Children |
October 11, 2006 |
| Affidavit For Dependents Other Than Spouse Or Child |
October 11, 2006 |
| Authorization For Release Of Student Information |
October 11, 2006 |
| Certification Of Acceptance |
October 11, 2006 |
| Individual Self-Insurer Application |
September 27, 2006 |
| Application For Membership In A Group |
September 27, 2006 |
| Application For Group Self-Insurance |
September 27, 2006 |
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