ARKANSAS WORKERS' COMPENSATION COMMISSION Form AR-4 Authority: Ark. Code Ann. §11-9-810 Revised: 1-1-2011 324 Spring Street, Little Rock, AR 72201 Mail: P. O. Box 950, Little Rock, AR 72203-0950 501-682-3930 / 1-800-622-4472 REPORT OF COMPENSATION PAID/SUSPENSION OF PAYMENTS 4 Employee S.S. Number State Zip Code AMENDED REPORT Closing Report Report of Payment Suspension AWCC File No. Death/PTD Maximum Liability Update Report (additional payments only) Employee Name (Last, First, MI) Carrier Claim No. Employer Name City Carrier or Self-Insured Name Claims Office Location (mailing address) DISABILITY INFORMATION Date of Injury Last Day Employee Worked Date Employee Able to RTW Return - to - Work Date Total days worked between injury and date able to RTW _____________ COMPENSATION INFORMATION: COMPENSATION PAYMENTS MADE: (1) TTD Weeks (2) TPD Weeks (3) PPD Weeks (4) (5) Weeks PTD Weeks for Death Days Days Days $ (9) Defense Attorney Fees *(10) Other (Compensation Related) (11) Hospital Expenses (12) Medical Expenses (13) Drugs, Medicine (14) Funeral Expenses (15) Rehabilitation *(16) Other (Expense Related) (1 - 16) GRAND TOTAL (6) Lump Sum payment (7) Joint Petition settlement (8) Claimant Attorney Fees SUSPENSION OF PAYMENTS OF COMPENSATION Date of Suspension of Com pensation: Comp ensation paid through CERTIFICATION I certify that the forego ing is a co mple te and accurate rep ort accord ing to the records of the insurer p ertaining to payments of compensation and suspe nsions of paym ent information. I further certify that a copy of this report or equivalent information has been provided to the em ployee or beneficiaries. (date). Reason for Suspension: Signature Printed or Typewritten Name Title Date American LegalNet, Inc. www.FormsWorkFlow.com AWC C Form 4 (Report of P ayment) A Final Report is due within 30 days o f the last compe nsation paym ent. [Ark. Cod e Ann. § 11 -9-810(b)(1)] Every Form 4 must provid e the AW CC file numb er. Carriers must list their NAIC numb er. (National Association of Insurance Commissioners) Emp loyers must list their Federal Em ployer Identification numbers. Form 4 is for all end -of-paym ent rep orts, i.e.: 1. The suspension of benefits; reason for suspension must be given. 2. The closing of a medical-only case that was accidentally opened by the respondent on Form 1 or by a claimant on Form C. 3. The Final Rep ort of a com pensable case, d etailing all p ayments. Forms 1, 2, and 3 (or na rrative m edica l repo rt) are required for these cases. 4. Maximum liability being reached in cases involving death or permanent total disability (both the Compensation Section and the Susp ension of Payments Sectio n are to be co mple ted). T he bo x for D eath/P TD Maximu m Liability must be marked. 5. *Other in (10) of the Comp ensation Inform ation Section includ es benefits not listed elsewhere, such as interest and penalties. *Other in (16) would includ e cou rt repo rter fees and mileage reimb ursem ent. Information on Form 4 may be supplied by the Suppo rt Services Division. For a specific case, refer to the Office Services Division, which processes Form 4 and closes the case. (1-800-622-4472 or 501-682-3930) Ark. Code Ann. §1 1-9-106(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 b enefit or payment; or obtaining or avoiding wo rkers' compensation coverage or avoiding paym ent of the proper insurance premium, or who aids and abets for any o f said purpo ses, 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 Perma nent Total Disability Trust Fund administered by the Workers' Com pensation Commission." American LegalNet, Inc. www.FormsWorkFlow.com