Form AR-C Au tho rity: A rk. C od e A nn . § 11-9-702 Revised: 1-1-2001 Updated: 6-16-14 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) 1-800-852-5376 (Springdale Office) C (A rea C ode ) H om e Ph one No . Zip Code CLAIM FOR COMPENSATION EMPLOYEE INFORMATION (Please Print in Ink) E m p lo ye e' s L a st N am e F ir st N am e M. I. Social Security Number Da te of B irth Street Address or P.O. Box Child Sup port O bligation : City Payable to: State Cur rent Past Due EM PLOY ER INF OR MAT ION (Please Print) Emp loyer's Name (na me und er which d oing business) (Area Code) Employer's Telephone No. Employer's Street Address Em ploye r's City State Zip Code AC CID EN T IN FO RM AT ION (Please Print) Employer's Workers' Compensation Insurance Carrier ( if known) Place of Accident (City, State) Date of Accident Brie fly de scrib e the cau se o f inju ry an d the part o f bo dy in jured : _________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ CL AIM INF OR MAT ION (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 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 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 f utu re p hy sica l, me nta l or e mo tion al co nd ition . I hereby waive my physician- and psychotherapist-patient privilege. A photostatic copy of th is auth oriza tion s hall b e as e ffectiv e an d va lid as th e orig inal. Da te: Signature: If claimant is represented by an attorney, that legal representative must sign below pursuant to Ark. Code Ann. §11-9-717. Nam e and Ad dress o f Attorn ey Sig nature C American LegalNet, Inc. www.FormsWorkFlow.com AWCC Form C (Claim for Compensation) Ark. Code Ann. § 11-9-702 allows employees or their dependents 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. 2. 3. 4. 5. 6. Typ e or print in ink. D o not use pencil. Inform ation m ust be com plete. Employe r's busine ss nam e is nee ded, not the nam e of the forem an or supervisor. Date of injury is essential. If specific date unavailable, as in the case of diseases, list date employee knew of the condition. Street address o f employer must be g iven to allow the AW CC to contact the correc t employe r. Employee's signature at bottom is required. Questions on a specific Form C m ay 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 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 w ith applicable law to the D eath and Permanent Total Disability Trust Fund administered by the Workers' Compensation Commission. Ark. Code Ann. §11-9-115 requires applicants for workers' compe nsation ben efits to state if child support paym ents 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 paper of 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 improper purpose or for delay. Violators of this provision may be subject to sanctions, which may include payment of reasonable expenses incurred by others and reasonable 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