Form AR-A ARKANSAS WORKERS’ COMPENSATION COMMISSION 324 Spring Street, Little Rock, AR 72201 Mail: P.O. Box 950, Little Rock, AR 72203-0950 501-682-3930/1-800-622-4472 Ark. C ode Ann. § 11-9-102(9)(D ), 11-9-402 Revised 1-1-2008 A Be sure to include: Application, Notarized Certificate, and Check or M oney Ord er for $ 50 m ade payab le to Arkansas Workers’ Compensation Com mission APPLICATION FOR CERTIFICATE OF NON-COVERAGE Please note prior to completing this Application: 1. 2. 3. 4 5. 6. Arka nsas law generally requires workers’ co mpe nsation insurance for every emplo yment: (a) in which three (3) or more employees are employed by the same employer; (b) in which two (2) or more emp loyees are engaged in building or building repair work; (c) in which one (1) o r more employee is emp loyed by a co ntracto r who subcontracts any part of his contract; (d) in which one (1) or more employee is employed by a subcontractor. In order to arrive at the above number, employee is defined to include, but is not limited to, an owner, a sole proprietor, a partner or partners who devote full-time to the partnership, a full-time employee, a part-time employee, and a volunteer. It is a felony for any employer or contractor to compel any employee or sub-subcontractor to pay for, or contribute to, workers’ compensation insurance coverage. It is a felony for any employer or contractor to compel any employee or sub-contractor to obtain a Certificate of Non-Coverage. Add ress below must be the applicant’s OWN business or ho me address, NO T add ress of company to whom the applicant is contracting or for whom the applicant is doing a pro ject. Any questions or co mmen ts may be referred to your workers’ comp ensation insurance agent or the Arkansas W orkers’ Compensation Comm ission. Applicant Information (please print): (Printed Name) Social Security No. Signature Date Comp any Name (list ALL names under which you yourself conduct business): Business A ddress: 1. G Yes G No Does the business employ others in addition to the parties listed above? 2. G Yes G No Is the company or companies incorporated? 3. If you or any of your employees are cove red under a workers’ co mpe nsation policy, please list: Insurance C omp any: Policy No .: If answers to any questions above are “yes,” provide the application to your insurance agent for further processing during the writing of your workers’ com pensation insuranc e policy. The agent is to provide the following information, then forward the Application to the Arkansas W orkers’ Compensation Commission at the address below: Agent’s Name Agent’s Ad dress (City) (State) (Zip Code) Agent’s Signature If answers to ALL questions above are “no”, submit Form A to the Coverage/Compliance Section, Arkansas Workers’ Compensation, P.O. Box 950, Little Rock, Arkansas 7220 3-0950 o r deliver to 324 Spring St., Little Rock, Arkansas 72201. Your Application will be processed and action comm unicated back to you within ten (10 ) working da ys. SEE IMPORTANT INFORMATION ON OTHER SIDE American LegalNet, Inc. www.FormsWorkflow.com AWCC Form A (Application for Certificate of Non-Coverage) Form A is not used for exclusion from a workers’ compensation policy by corporations or corporate officers, sole proprieto rs, partners of a partnership, members of a limited liability company, members of a professional association, or a self-employed employer who is not a subcontractor and who owns and o perates his or her own business. Exclusions of corporate officers from coverage is handled directly by the agent/carrier. If the answer is yes to Question 1 on Form A, the application for no n-coverage will be rejected unless: 1. The agent furnishes a copy of the declarations page or the National Council on Compensation Insurance application for proof of workers’ compe nsation cove rage; or 2. The applicant has furnished proof that coverage is not required. Assistance with Form A and/o r the acco mpa nyin g affidav it is available from the AW CC Compliance Section. General information is available from the AWCC at 800-622-4472 outside of Pulaski County, or 501-682-3930. Ark. Code Ann. §11-9-106(a): “Any perso n or entity who willfully and knowingly mak es any material false statement or representation, who willfully and knowingly omits or conceals any material information, or who willingly and knowingly employs any device, scheme, or artifice for the purpose of : ob taining an y bene fit or paym ent; defeating or wron gfully increa sing or wrongfully decreasing any claim for benefit or paym ent; 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 Perm anent Total Disability Trust Fund adm inistered by the W orkers’ Compe nsation Commission.” (Revised 1-1-2008 ) American LegalNet, Inc. www.FormsWorkflow.com AFFIDAVIT FOR CERTIFICATE OF NON-COVERAGE To the Arkansas Workers’ Compensation Commission: You are hereby notified that the undersigned who has submitted an application for a Certificate of Non-Coverage is a: ( ) Sole proprietor ( ) Partner ( ) Member of a Limited Liability Company and, being engaged as such in the State of Arkansas, has elected to be excluded as an employee and from the mandatory insurance requirement of the Arkansas workers’ compensation laws: Signed: Social Security Number (Street, City, State, Zip) Dated this day of ,2 STATE OF ARKANSAS COUNTY OF Before me, the undersigned authority, on this day appeared who acknowledged that he/she executed the foregoing for the purposes and consideration therein stated. WITNESS by my hand and my notarial seal this day of ,2 Notary Public My Commission Expires: American LegalNet, Inc. www.FormsWorkflow.com