Notice Of Claimant Information Update Change Of Address
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Notice Of Claimant Information Update Change Of Address Form. This is a Arkansas form and can be use in Workers Comp.
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Tags: Notice Of Claimant Information Update Change Of Address, SF-1, Arkansas Workers Comp,
Form SF-1
ARKANSAS WORKERS’ COMPENSATION COMMISSION
Rev. 1-1-2001
Autho rity:
Ark. Code Ann.
§11-9-205
SPECIAL FUNDS DIVISION
SF-1
501 Woodlane Drive, Suite 101, Little Rock, AR 72201
501-682-5187 / 1-866-880-8444 (Toll-free)
NOTICE OF CLAIMANT INFORMATION UPDATE / CHANGE OF ADDRESS
AWCC File No.
Claimant:
I have a change of (check all that apply): G mailing address, G residence address, G telephone number(s),
G emergency contact person, to be effective on _________________________________, 2________.
******************************************************************************************
Old Address:
City
Home Tel. (AC)
State
ZIP
Day/Work Tel. (AC)
New Address:
Mail address (if different)
City
Home Tel. (AC)
State
ZIP
Day/Work Tel.(AC)
Emergency Contact: Name
Home Tel.(AC)
Relationship
Day/Work Tel.(AC)
Address
City
Claimant signature
State
ZIP
Date
Ark. Code Ann. §11-9-1 06(a): “Any pers on or enti ty wh o willfu lly and know ingly makes any material false s tatemen t or repres enta tion, who willfu lly and know ingly
omits or con ceals any m ateri al informa tion, or who w illfully an d kn owin gly em ploys any d evice, schem e, or artifice for th e pu rpos e of: obtaining any benefit or
payment; defeatin g or w rongfully increasing or w rongfully decreasing an y claim for benefit or payment; or obtaining or avoid ing workers’ comp ensation coverage
or avoiding payme nt of the proper insu rance prem ium, or who a ids and ab ets for any of said purp oses, under th is chapter sha ll be guilty of a Class D felony. Fifty
percent (50%) of any criminal fine imposed and c ollected 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.”
SF-1
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