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)

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)

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.

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.

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).

(9/14/1998)

The following state regulations pages link to this page.