Form HS-31-E Ark. Code Ann. §11-9-409(d) & AWCC R ule 31 Rev. 1-1-2001 ARKANSAS WORKERS' COMPENSATION COMMISSION HEALTH & SAFETY DIVISION 324 Spring Street, Little Rock, AR 72201 Mail: P. O. Box 950, Little Rock, AR 72203-0950 501-682-3930 / 1-800-622-4472 HS31-E Evaluation of Accident Prevention Services of Arkansas Workers' Compensation Insurance Carriers List of Field Safety Representatives (FSR)/Approved Professional Safety Sources (APSS) Status Name Current telephone no. Employee C o n t r a c to r FSR no. APSS no. ________________________________________ Company Name ________________________________________ Prepared By (Name) ________________________________________ Date HS-31-E American LegalNet, Inc. www.FormsWorkFlow.com