18 95 WCC Form SF-6: Affidavit for Dependents other than Spouse or Child [New] [Filed with the Special Funds Division of the Arkansas Workers' Compensation Commission by the dependent beneficiary.
| Jurisdiction | Arkansas |
| Library | Arkansas Form Book - Complete (2024 Supplement) |
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- Books and Journals
- Chapter 18 WORKERS' COMPENSATION
- Arkansas Workers' Compensation Commission Forms
- 18 70 WCC Form I-A1: First Report of Injury or Illness [Filed by Respondent]
- 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]
- Special Funds Division Forms
- 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]
- 18 94 WCC Form SF-5: Guardian's Affidavit - Dependent Child(ren) [New] [Filed with the Special Funds Division of the Arkansas Workers' Compensation Commission by the guardian of a dependent child]
- 18 95 WCC Form SF-6: Affidavit for Dependents other than Spouse or Child [New] [Filed with the Special Funds Division of the Arkansas Workers' Compensation Commission by the dependent beneficiary.
- 18 96 WCC Form SF-8: Authorization for Release of Student Information [New] [Completed by dependent student beneficiary] and sent to Arkansas Workers' Compensation Commission Special Funds Division.
- 18 97 Arkansas Workers' Compensation Commission Forms Training Materials [New]
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