Arkansas Form Book - Workers' Compensation Edition (includes 2024 supplement)

Front Matter

• Front Matter
• PREFACE
• Introduction

PREFACE

• Front Matter
• PREFACE
• Introduction

Introduction

• Front Matter
• PREFACE
• Introduction

Chapter 1 Acknowledgments and Affidavits

• Chapter 1 ACKNOWLEDGMENTS AND AFFIDAVITS
• NOTE ON ACKNOWLEDGMENTS
• 01 01 ACKNOWLEDGMENT: INDIVIDUALS
• 01 02 ACKNOWLEDGMENT: ENTITIES AND TRUSTS
• 01 03 ACKNOWLEDGMENT: ATTORNEY IN FACT
• 01 04 AFFIDAVIT: GENERAL
• 01 05 AFFIDAVIT: VERIFICATION OF PLEADINGS
• 01 06 AFFIDAVIT: CUSTODIAN (HOSPITAL RECORDS ACT)
• 01 07 AFFIDAVIT: CUSTODIAN OF THE RECORDS

Chapter 18 Workers'''''''''''''''' Compensation

• Chapter 18 WORKERS' COMPENSATION
• OVERVIEW
• 18 01 WCC LETTER OF REPRESENTATION
• 18 02 WCC FORM AR-C
• 18 03 WCC LEGAL REPRESENTATION AND FEE AGREEMENT
• 18 21 WCC AUTHORIZATION FOR WORKERS' COMPENSATION COMMISSION TO RELEASE MEDICAL RECORDS
• 18 22 WCC EMPLOYMENT RECORDS AUTHORIZATION
• 18 23 WCC RELEASE OF MEDICAL INFORMATION
• 18 24 WCC CHILD SUPPORT AFFIDAVIT
• 18 25 WCC MILEAGE AND MEDICAL FORM FOR CLAIMANT'S USE
• 18 31 WCC JOINT PETITION QUESTIONNAIRE
• 18 32 WCC JOINT PETITION WITHOUT MEDICARE SET-ASIDE
• 18 33 WCC JOINT PETITION WITH MEDICARE SET-ASIDE
• 18 34 WCC JOINT PETITION INDEMNITY-ONLY FOR MEDICARE CLAIMANTS
• 18 35 WCC JOINT PETITION ORDER FOR INDEMNITY-ONLY FOR MEDICARE CLAIMANTS
• 18 36 WCC AFFIDAVIT OF CLAIMANT FOR MEDICARE BENEFICIARY SETTLEMENT
• 18 40 WCC INTERROGATORIES AND REQUESTS FOR PRODUCTION OF DOCUMENTS PROPOUNDED TO CLAIMANT
• 18 41 WCC INTERROGATORIES AND REQUESTS FOR PRODUCTION OF DOCUMENTS PROPOUNDED TO RESPONDENTS
• 18 51 WCC PRELIMINARY NOTICE
• 18 52 WCC RESPONSE TO PREHEARING QUESTIONNAIRE
• 18 53 WCC INDEX OF EXHIBITS
• 18 54 WCC NOTICE OF APPEAL TO THE FULL ARKANSAS WORKERS' COMPENSATION COMMISSION FROM ALJ DECISION
• 18 55 WCC BRIEF TO THE ARKANSAS WORKERS' COMPENSATION COMMISSION
• 18 56 WCC NOTICE OF APPEAL TO COURT OF APPEALS FROM WORKERS' COMPENSATION COMMISSION
• 18 66 WCC THIRD PARTY MOTION TO INTERVENE
• 18 67 WCC THIRD PARTY COMPLAINT IN INTERVENTION
• 18 68 WCC THIRD PARTY DISTRIBUTION PETITION
• 18 69 WCC THIRD PARTY DISTRIBUTION ORDER
• 18 70 WCC Form I-A1: First Report of Injury or Illness [Filed by Respondents]
• 18 71 WCC Form AR-C: Claim for Compensation [Filed by Injured Employee or Employee's Attorney]
• 18 72 WCC Form AR-2: Employer's Intent to Accept or Controvert Claim [Filed by Respondents - usually completed by Claims Adjuster]
• 18 73 WCC Form AR-3: Physician's Report [Completed by physician]
• 18 74 WCC Form AR-4: Report of Compensation Paid/Suspension of Benefits [Filed by Respondents]
• 18 75 WCC Form AR-A: Application for Certificate of Non-Coverage [Filed by Individual Who is a Sole Proprietor, Partner or Member of a Limited Liability Company who elects to not be considered an employee.]
• 18 76 WCC Form AR-D: Death and Permanent Total Disability Acceptance/Update [Filed with the Arkansas Workers' Compensation Commission by Respondents]
• 18 77 WCC Form AR-H: Health Care Notice for Employees Under Managed Care [This form is posted by the Employer]
• 18 78 WCC Form AR-L: Claimant's Lump Sum Request/Respondent's Position [This form is completed by both the Claimant and the Respondent]
• 18 79 WCC Form AR-M: Monthly Report on Medical-Only Injury Data [This form is completed by Respondents]
• 18 80 WCC Form AR-N: Employee's First Notice of Injury [Completed by the Claimant and given to his or her employer upon initial reporting of the injury]
• 18 81 WCC Form AR-O: Contact Designation Form for Claim Office/Medical Billing /Underwriter/Administrator [This form is filed by the Workers' Compensation Insurance Carrier or Self-Insured with the Arkansas Workers' Compensation Commission]
• 18 82 WCC Form AR-P: Workers' Compensation Instructions to Employers and Employees [This form is posted by the Employer]
• 18 83 WCC Form AR-R: Report of Mediation Conference [This form is completed by the Mediator at the Arkansas Workers' Compensation Commission]
• 18 84 WCC Form AR-S: Supplemental Report [This form is filed by Respondents with the Arkansas Workers' Compensation Commission]
• 18 85 WCC Form AR-V: Verification of Permanent Total Disability [This form is sent by the Special Funds Division of the Arkansas Workers' Compensation Commission or the Respondent to the Claimant to complete]
• 18 86 WCC Form AR-W: Wage Statement Immediately Preceding Injury Date [Filed by Respondents]
• 18 90 WCC Form SF-1: Notice of Claimant Information/Change of Address [Filed by the injured employee with the Special Funds Division to notify of a change of address or Emergency Contact]
• 18 91 WCC Form SF-2: Guardianship Affidavit (Court Appointed/Non-Minor) [Filed with the Special Funds Division of the Arkansas Workers' Compensation Commission by the Guardian for the injured employee]
• 18 92 WCC Form SF-3: Power of Attorney Notice and Affidavit [Filed with the Special Funds Division of the Arkansas Workers' Compensation Commission by the person holding power of attorney for the injured employee]
• 18 93 WCC Form SF-4: Surviving Spouse Notice and Affidavit [Filed with the Special Funds Division of the Arkansas Workers' Compensation Commission by the spouse of a deceased employee certifying that he or she has not remarried]

Chapter 20 Miscellaneous

• Chapter 20 MISCELLANEOUS
• NOTE: FORMATTING INSTRUCTIONS
• 20 01 DURABLE POWER OF ATTORNEY
• 20 02 GENERAL POWER OF ATTORNEY
• 20 03a STATUTORY FORM POA
• 20 03b STATUTORY POA CERTIFICATION
• 20 04 LIVING WILL DECLARATION
• 20 05 OPTIONAL ORGAN AND TISSUE DONATION
• 20 06 PETITION FOR CHANGE OF NAME
• 20 07 ORDER FOR NAME CHANGE
• 20 08 PETITION FOR REMOVAL OF DISABILITIES
• 20 09 ORDER FOR REMOVAL OF DISABILITIES
• 20 10 NOTICE OF REPRESENTATION
• 20 11 SCHOOL RECORDS AUTHORIZATION
• 20 12 ASSIGNMENT ON WRITTEN INSTRUMENT
• 20 13 ASSIGNMENT OF OPEN ACCOUNT
• 20 14 ASSIGNMENT BY SEPARATE INSTRUMENT
• 20 15 ASSIGNMENT OF MORTGAGE AND NOTE
• 20 16 ASSIGNMENT OF JUDGMENT
• 20 17 ASSIGNMENT OF LEASE
• 20 18 HIPAA-COMPLIANT MEDICAL RECORDS RELEASE
• 20 19 CHECKLIST FOR VALID AUTHORIZATION
• 20 20 BUSINESS ASSOCIATE AGREEMENT
• 20 21 REQUEST FOR INFORMATION - INDIVIDUAL
• 20 22 REQUEST FOR INFORMATION - COVERED ENTITY
• 20 23 JOINT QUALIFIED PROTECTIVE ORDER
• 20 24 CONFIDENTIALITY AGREEMENT FOR SUBCONTRACTOR OF BUSINESS ASSOCIATE