ARKANSAS WORKERS’ COMPENSATION COMMISSION Form AR-S S 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. § 11-9-529 Revised: 1-1-2001 SUPPLEMENTAL REPORT Carrier Claim No. Employee Name (Last, First, MI) Employee SS Number Employer Name FEIN No. State Carrier Or S elf-Insur ed Name NAIC No. AWC C File No. City Zip Code Claims Office Address 1. Date o f injury: 2. Date em ployee be gan losing time from work : 3. Has employee returned to work? “ Yes “ No If yes, give date 4. If employee has returned to work, is he/she earning the same wages as before the injury? “ Yes “ No If not, please explain: 5. Has employee died? “ Yes “ No If yes, give d ate of death: ADDITIONAL INFORMATION CERTIFICATION I certify that the information above is accurate acco rding to the employer’s/carrier’s record s. Signature Printed or Typewritten Name Title Date S American LegalNet, Inc. www.FormsWorkFlow.com AWCC Form S ( Supplemental Report) This form reports any change-in-status, including, but not limited to: 1. The injured employee is back at work and drawing wages; 2. The injured employee is losing time again; 3. The injured employee has died; Employers need to file Form S promptly. Carriers file the form to fill in any "gaps" in time on AWCC Form 4 when the case is being closed. Contact the AWCC Office Services Section for help with the Form S. General information is available from the Support Services Division (1-800-622-4472 or 501-682-393 0) . 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.” American LegalNet, Inc. www.FormsWorkFlow.com