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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 1or
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 1or 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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