Rejection of Coverage - Executive Officers

Change of Ownership Form ERM14

Form 1 Employer's First Report of Injury or or Illness

Deductible Notice AR Workers' Compensation

Employer's First Report of Injury or Illness: Those involving either more than 7 days of lost time or indemnity payments require Form 1 -Employers do NOT fill in the shaded areas. 1. In the Occurrence Section list the date the employer first knew of the injury. The 10 days to report begin either on the date of disability or the date the employer was notified, whichever date is later. 2. Give the name of the carrier. An insurance agency or third party administrator should be listed in the Preparer's Section. A carrier can pre-print its name and address in the Carrier Section to help clients properly report. 3. Specify the carrier Federal Employer Identification Number (FEIN) in the Carrier Section. 4. Type or print in ink. An illegible, incomplete Form 1 will be returned.

Form N- EMPLOYEE’S NOTICE OF INJURY

EMPLOYEE’S NOTICE OF INJURY - NOTICE TO EMPLOYEE - Fill out this form to give to your employer immediately. Ark. Code Ann. § 11-9-701. Notice of injury or death. (a)(1) Unless an injury either renders the employee physically or mentally unable to do so, or is made known to the employer immediately after it occurs, the employee shall report the injury to the employer on a form prescribed or approved by the Workers’ Compensation Commission and to a person or at a place specified by the employer, and the employer shall not be responsible for disability, medical, or other benefits prior to receipt of the employee’s report of injury. 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.

Application for Certificate of Non-Coverage

(Application for Certificate of Non-Coverage) Form A is not used by corporations or corporate officers to be excluded. Exclusion of corporate officers is handled directly by the agent/carrier. If the answer is yes to Question 1 on Form A, the application for non-coverage will be rejected unless: 1. The AWCC has Form I (insurance coverage card) for the employment from a carrier; or 2. The agent furnishes a copy of the declarations page or the National Council on Compensation Insurance application for proof of workers' compensation coverage; or 3. The applicant has furnished proof that coverage is not required.

AWCC Form S

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..

Applicant Information - Form needed on all Applicants

Regular Worker's Compensation Application

Assigned Policy Worker's Compensation Application

BUSINESS OWNERS - RETAIL, SERVICE and MANUFACTURING QUOTE APPLICATIONS