ARKANSAS WORKERS' COMPENSATION COMMISSION Form AR- 2 Authority: Ark. Code Ann. §119-803, -810 Revised 1-1-2013 324 Spring Street, Little Rock, AR 72201 Mail: P. O. Box 950, Little Rock, AR 72203-0950 501-682-3930 / 1-800-622-4472 2 Employee SS Number Fed. Employer I.D. No. State Zip Code EMPLOYER'S INTENT TO ACCEPT OR CONTROVERT CLAIM Initial Filing AWCC File No. Amended Filing Carrier Claim No. Employee Name (Last, First, MI) Employer Name Address City Carrier or Self-Insured Name Is this a medical only claim? Y es N o Claims Office Name, Address, and Phone Is this a PPD-Only Claim? Y es N o COMPENSATION (if not applicable, skip to next section) Da te of First Comp. C heck Da tes Covered by F irst Check Body Part Inju red W as D isab ility C ontin uo us D ur ing th e Fir st 8 D ays? Y es N o First D ay o f Disa bility .00 Average W eekly Wa ge W kly T TD Com p. Rate (rounded) Da te Indemnity T riggered STATEMENT OF POSITION Date of injury or death: _______________ City, State of Injury: ____________________ State your position. If controverting, state the grounds therefore: ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ DEATH CASE DATA List all Dependents below: (If more space is needed, attach supplemental sheet) If no Dependents, check here: Attach Death Certificate of Deceased Employee and Birth Certificates for Dependent Children Name of dependent Date of 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. Title: Signature Printed or Typewritten Name Phone: 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 case and report payment or to controvert. 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 day after the employer has notice of the injury or death. (Ark. Code Ann. §11-9-802) The AWCC is notified "upon making the first payment." (Ark. Code Ann. §11-9-810) A controversion notice is due on or before the 15th day after notice of the death or alleged injury. (Ark. Code Ann. §11-9-803) Therefore, AWCC Form 2 in all cases is required by the 15th day from (a) the day of disability or (b) the day the employer is aware of the alleged incident, whichever date is later. 2. 3. 4. Be sure to include on AWCC Form 2: 5. 6. A mark in either the Initial Filing Box or Amended Filing Box. 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. 8. Form 2 is NOT interchangeable with the required written response to the 15-day letter for Form C. If respondents 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 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. 9. Questions about a specific Form 2, or general information or assistance on completing or filing a Form 2, may be directed to the AWCC Operations and Compliance Division, which processes this form (1800-622-4472 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 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 with applicable law to the Death and Permanent Total Disability Trust Fund administered by the Workers' Compensation Commission. Ark. Code Ann. §11-9-717: Any perso n or atto rney signin g a claim, r equ est 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 la w or a good fa ith argum ent for extension, modification or reversal of existing law; and is not interposed for a ny im proper p ur pose o r for d elay . Vio lato rs of this p rovision m ay be su bject to sanction s, which may include pay ment of reasonab le 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. 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