ARKANSAS WORKERS’ COMPENSATION COMMISSION Form AR- 2 2 324 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. §11-9-803, -810 Revised 1-1-2001 EMPLOYER’S INTENT TO ACCEPT OR CONTROVERT CLAIM “ Initial Filing AWCC File No. ” Amended Filing Carrier Claim No. Employee Name (Last, First, MI) Employee SS Number Employer Name Address Fed. Employer I.D. No. City State NAIC No. Carrier or Self-Insu red Name Zip Code Claims Office Address COMPENSATION (if not applic able, skip to next section) Date of Injury City, State of Injury Dates Covered by First Check Body Part Injured First Date Indemni ty Triggered (Disability Da te) Check Condition if Applicable: Date of First Comp. Check Average Weekly Wage Weekly Comp. Rate “ Medical - Only Claim (no indemnity due) “ PPD-Only Case “ “ “ TPD PTD Death CONTROVERSION SECTION Date of injury or death: Reason for controver ting claim: DEATH CASE DATA List all Dependents below: (If more space is needed, attach supplemental sheet) Attach Death Certificate of Deceased Employee and Birth Certificates for Dependent Children Name of dependent Date of birth If no Dependents, check here: “ Relationship to deceased Weekly benefit amount CERTIFICATION I certify that the foregoing is a complete and accurate report according to the records of the insurer pertaining to first payment, controversion and beneficiary information. I further certify that a copy of this report or equivalent information has been provided to the employee or beneficiaries. Signature Printed or Typewritte n Name Title Telephone No. Date If insurer 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 2 American LegalNet, Inc. www.FormsWorkFlow.com AWCC Form 2 (Employer's Intent to Accept or Controvert Claim) A form used to accept a ca se and rep ort payme nt or to contr overt. AWCC Form 2 also is used to amend positions taken earlier. Help With AWCC Form 2: 1. The first payment to the employee is due by the 15th d ay after the emp loyer has no tice of the injury o r death. (Ark. Code Ann. §11-9-802) 2. The AWCC is notified "upon making the first payment." (Ark. Code Ann. §11-9-810) 3. A contro version no tice is due on o r before the 1 5th day after no tice of the dea th or alleged injury. (Ark. Code Ann. §11-9-803) 4. Therefore, AWCC Form 2 in all cases is requ ired by the 1 5th day from (a) th e day of disability or (b) the day the employer is aware of the alleged incident, whichever date is later. Be sure to include on AWCC Form 2: 5. A mark in either the Initial Filing Box or Amended Filing Box. 6. The AWCC File Number (obtained from AWCC Form A-110 ) and your company's file number for this case. Be sure to bear in mind: 7. Form 2 is NOT interchangeable with the required written response to the 15-day letter for Form C. 8. If respond ents need additional time for investigation, an extension request must be sent in before the Form 2 deadline. Using Form 2 to report that the respondent needs more time is invalid. If anything is written in the Controversion Section ("we are investigating"), the AWCC will consider the case controverted. 9. If a case is opened at the AWCC on Form 1 or Form C, an AWCC Form 2 is required, even if the case upon investigation is determined to be a medical-only claim. Questions about a spec ific Form 2 ma y be answ ered by the A WCC Office Service s Division, which processes this form. General information may be obtained from the AWCC 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 conceals any material information, or who willfully and knowingly employs any device, scheme, or artifice for the pu rpose of: obtaini ng any benefit or payment; defeati ng or wrongfully increasin g 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 with applicable law to the Death and Permanent Total Disability Trust Fund administered by the Workers’ Compensation Commission.” Ark. Code Ann. §11-9-717: (Summary) 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 reasona ble 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, dep osition or other scheduled matter. American LegalNet, Inc. www.FormsWorkFlow.com