ARKANSAS WORKERS’ COMPENSATION COMMISSION Form AR -D D 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. §11-9-502 & Rule 28 Revised: 1-1-2001 DEATH and PERMANENT TOTAL D ISABILITY ACCEPTANCE/UPDATE “ Initial Report “ Amended R eport AWCC File No. Carrier Claim No. Employee Nam e (Last, First, MI) Employer Name Employer FEIN No. Carrier or Self-Insured Name NAIC No. Employee SS Numb er City State Zip Code Claims Office Location (City, State) CASE INFORMATION Date of Injury Death Date (if applicable) Healing Period Ended Date Acceptance or Award of PTD Total Payments for we ekly benefits as of Dec. 31, (year) (excluding TTD) $ date that payment by insurer will end because of maximu m liability : If this case has been controverted, but no t closed, check here: “ This case was closed on (Attach Supporting D ocumentation). Exact CASE STATU S CHA NGES (since last report) 1. “ Payment ceased on because of: “ death, “ remarriage, “ lump sum paym ent, “ joint petition settlements, “ change in disability status, “ subrogation (payment to resume on: ) or because “ insurer has reached maximum liability. Because payments ended, A WCC Form 4 was subm itted or is attached. 2. “ Payment to som e dependents changed because of one or more o f the following: “ death or “ remarriage of spouse, “ increase in dependents, “ marriage or “ death of dependent child, “ dependent attained ma ximum age, or “ other. (Explain “other” on bac k.) 3. “ Widow/widower remarried on . The lump sum payment was $ . Remaining dependent(s) benefits increased on . 4. “ Payment to children con tinues because of “ single, full-time student status or “ incapacity. (Supporting docu mentation must be attached when transferring liability to the Trust Fun d for payment.) and (check only one): “ Insurer accepts death as stemming from disabling accident 5. “ Employee on PTD died on and has begun payments to depend ents or “ Insurer has declined to accept death as accident- or illness-related in connection with employment. CERTIFICATION In compliance with A WCC requirements, the above is a true, accurate repo rt. Signature Printed or Typewritten Name Address Title Date Telephone No. D American LegalNet, Inc. www.FormsWorkFlow.com CURRENT PAYMENTS Claimant/dependents are receiving benefits based on an average weekly wage of $ Explain any adjustments to the weekly benefits. Total weekly benefits $ Name Relation ship . . Age/Birthda te Amt. Per Week / - - $ / - - $ / - - $ / - - $ / 1. - - $ (Address) 2. (Addres s - if different) 3. (Addres s - if different) 4. (Addres s - if different) 5. (Addres s - if different) Check here “ if other names and addresses are listed by attachment to this AWCC Form D. NOTICE Once notification is received from the Death and Permanent Total Disability Trust Fund of Certification of Acceptance of the targeted date of last payment discharging the employer/carrier’s obligation pursuant to Ark. Code Ann. §11-9-502(b), no additional Form D is required, unless there is a change in the status of a permanently totally disabled worker or the eligible dependents of a deceased worker. In the event of a change, an amended Form D must be filed within 15 calendar days of such change. In n o event shall the employer or carrier cease bi-weekly pa yments for death or permanent total disab ility prior to filing a Form D and the approval of the date of termination of benefits by the Death and Permanent Total Disability Trust Fund. AWCC Form D (Death or Perman ent - Total Disability Case) AWCC Form D is due in January to report on the previous calender year and filed each year until a Certification of Acceptance is issued by the AWCC to the respondent. Form D’s importance and the need for its correct and timely filing cannot be overemphasized. Contact the AWCC Spec ial Funds Division for help with Form D. General Information is available from Support Services Division. (1-800-622-4472 or 501-682-3930) 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 knowingly omits or conc eals any material information, or who willfully and knowingly employs any device, scheme, or artifice for the purpose of: obtaining any ben efit or paym ent; defeating or wron gfully increasing or wrongfully decreasing any claim for benefit or payment; or obtaining or avoiding workers’ compensation coverage or avoiding payment of the proper insurance prem ium, o r wh o aids and a bets fo r any o f said p urpo ses, u nder this c hapte r sha ll be gu ilty of a C lass D felony. Fifty percent (50%) of any criminal fine imposed and collected und er .... th is sect ion sh all be pa id an d alloc ated in ac cord ance with applic able law to the Death a nd Perman ent Total Disability Trust Fund administered by the W orkers’ Compe nsation Comm ission.” American LegalNet, Inc. www.FormsWorkFlow.com