Arkansas Administrative Code › Agency 099 - Arkansas Workman's Compensation › Rule 099.00.98-001 - WCC Forms - C (Claim for Compensation), N (Notice to Employer/Notice to Employee), 2 (Employer's Intent), 4 (Closure Report)

Current through Register Vol. 49, No. 6, June, 2024
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WCC Form C
(Claim for Compensation)
Arkansas Code Annotated 11 -9-702
allows employees
			 or their dependents to file claims for compensation and sets time limits for
			 those filings.
This is the WCC's prescribed form for this action. It is filed
			 directly with the WCC, usually by claimants or their attorneys.
Care must be taken on
Form C:
1. Type or print in ink. Do not use
		  pencil.
2. Information must be
		  complete.
3. Employer's business
		  name is needed, not the name of the foreman or supervisor.
4. Date of injury is essential. If specific
		  date is unavailable, as in the case of diseases, list date employee knew of the
		  condition.
5. Address of employer
		  must be exact to avoid the WCC's contacting a wrong employer with the same or
		  similar name.
6. Employee's
		  signature at bottom is important It Is the only part of
Form C
that is to be written.
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WCC Form 2
(Employer's Intent)
A form to accept a case and report payment or to controvert
WCC Form 2
also is used to amend positions taken earlier.
Help With WCC Form 2:
1. The first payment to the employee is due
		  by the 15th day after the employer knows of the injury or death
(Arkansas
		  Code Annotated
		  11-9-802
		  ).
2. The WCC is notified
		  "upon making the first payment"
(ACA
		  11-9-810
		  ).
3. A controversion notice
		  is due on or before the 15th day following notice of the death or alleged
		  injury
(ACA
		  11-9-803
		  ).
4. Therefore,
WCC
		  Form 2
is required in all cases by the 15th day from (a) the day of
		  disability or (b) the day the employer is aware of the alleged incident,
		  whichever date is later.
Be sure to include on
WCC Form 2:
5. A mark in either the Initial Filing Box or
		  Amended Filing Box.
6. The WCC File
		  Number (obtained from
WCC Form A-110)
and your company's file
		  number for this case.
Be sure to bear in mind:
7.
Form 2
is NOT interchangeable
		  with the required written response to the 15-day letter for
Form
		  C.
8. If respondents need
		  additional time for investigation, an extension request must be sent in before
		  the
Form 2
deadline. Using
Form 2
to say the
		  respondent is investigating or needs more time is invalid. If anything is
		  written in the Controversion Section ("We are investigating"), the WCC will
		  consider the case controverted.
9.
		  If a case is opened at the WCC on
Form 1
or
Form C,
a
		  WCC
Form 2
is required, even if the case, upon investigation,
		  turns out to be a medical-only claim.
Questions about aspecific
Form 2
can be answered by
			 the WCC Office Services Support Staff, which processes this form. General
			 information can be obtained from the WCC Support Services Division.
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Form 4
(End of Payment)
A Final Report is due within 30 days of the last compensation
			 payment
(Arkansas Code Annotated
			 11-9-810
			 [b][1]).
Every
Form 4
must have the WCC File Number. Those
			 without the number will be returned to respondents. Also, respondents must list
			 the Carrier NAIC and the Federal Employer Identification numbers.
Form 4
is for all end-of-payment reports,
			 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.
A check mark on the medical-only line right
		  before the
Disability Section
is necessary.
3. The Final Report of a compensable case,
		  detailing all payments.
Forms 1, 2,
and
3
are
		  required for these cases.
4.
		  Maximum liability being reached in cases involving death or permanent and total
		  disability (both the Payments Section and the Suspension of Benefits Section
		  are to be completed).
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