Form AR-C Authority: Ark. Code Ann. § 11-9-702 Revised: 1-1-2001 Updated: 8-1-06 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 1-800-622-4472 (Little Rock Office) 1-800-582-5376 (Springdale Office) 1-800-354-2711 (Ft. Smith Office) C CLAIM FOR COMPENSATION EMPLOYEE INFORMATION (Please Print in Ink) Employee’s Last Name First Name M . I. Social Security Number Street Address or P.O. Box Ch ild S upp ort O bliga tion : “ Curre nt “ Past Due (Area Co de) H ome Phon e N o. State City Da te of Birth Zip Code Payable to: EMPLOYER INFORMATION (Please Print) Employer’s Name (name under which doing business) Employer’s Street Address (Area Code) Employer’s Telephone No. Emp loyer’s C ity State Zip Code ACCIDENT INFORMATION (Please Print) Employer’s Workers’ Compensation Insurance Carrier ( if known) Place of Accident (City, State) Date of Accident Briefly describe the cause of injury and the part of body injured: CLAIM INFORMATION (Please Print) If this claim is for initial benefits (no benefits, either medical or indemnity, have been received), what compensation benefits are you claiming? “ Temporary Total Disability “ Temporary Partial Disability “ Permanent Partial Disability “ Permanent Total Disability “ Rehabilitation “ Attorney Fees “ Medical Expenses “ Child Support “ Other (Explain): If this claim is for additional benefits, what specific benefits are you claiming? “ Additional Temporary Total “ Additional Temporary Partial Disability “ Additional Permanent Partial “ Additional Medical Expenses “ Rehabilitation “ Attorney Fees “ Child Support “ Other (Explain): If employee is deceased and claim is for death benefits, list name and address of all persons claiming death benefits: List person or entity (with address, phone number) which has paid benefits under a group health, disability or loss of income policy for the injury reported on this form: I hereby authorize any hospital, physician, psychotherapist or practitioner of the healing arts to furnish the bearer any information, including, but not limited to, copies of medical records concerning my past, present or future physical, mental or emotional condition. I hereby waive my physician- and psychotherapist-patient privilege. A photostatic copy of this authorization shall be as effective and valid as the original. Date: Signature: If claimant is represented by an attorney, that legal representative must sign below pursuant to Ark. Code Ann. §11-9-717. Name and Address of Attorney Signature C American LegalNet, Inc. www.FormsWorkflow.com AWCC Form C (Claim for Compensation) Ark. Code Ann. § 11-9-702 allows emp loyees or their dep endents to file claims for compensation and sets time limits for those filings. This is the AW CC's prescribed form for this action. It is filed directly with the AW CC, usually by claimants or their attorneys. Care must be taken on Form C: 1. Typ e or p rint in ink. D o not use pencil. 2. Inform ation m ust be comp lete. 3. Employer's business name is needed, no t the nam e of the fo rema n or supervisor. 4. Date of injury is essential. If specific date unavailable, as in the case of diseases, list date employee knew of the condition. 5. Street address of employer must be given to allow the AWC C to contact the correct employer. 6. Employee's signature at bottom is required. Questions on a specific Form C may be answered by the Legal Advisor Division (1-800-250-2511 or 501682-39 30). General information is available from the Support Services Division (1-800-622-4472 or 501682-39 30). Ark. Code Ann . §11-9-10 6(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 payment; or obtaining or avoiding workers’ compensation coverage or avoiding payment of the proper insurance premium, or who a ids and abets fo r any of said purpo ses, und er this cha pter shall be guilty of a Class D felony. Fifty percent (50%) of any criminal fine impo sed and co llected 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’ Com pensation Commission. Ark. Code Ann. §11-9-115 requires applicants for workers' compe nsation bene fits to state if child supp ort pa yments are due, to whom, and if payments are current or past due. Ark. Code Ann. §11-9-717: Any person or attorney signing a claim, request for benefits, controversion of benefits, request for hearing or other pa per o f a party, certifies the action is taken after reasonable inquiry; is well grounded in fact; is warranted by existing law or a good faith argument for extension, modification or reversal of existing law; and is not interposed for any impro per p urpo se or fo r delay. Violators of this provision may be subject to sanctions, which may include payment of reasonable expenses incurred by others and reaso nable attorney fees for responding to the claim, request or motion, or for failure to appear at a hearing, deposition or other scheduled matter. American LegalNet, Inc. www.FormsWorkflow.com