Arkansas > Workers Comp

Application For Certificate Of Non-Coverage AR-A - Arkansas

Application For Certificate Of Non-Coverage Form. This is a Arkansas form and can be used in Workers Comp .
 Fillable pdf Last Modified 4/1/2008
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Form AR-A ARKANSAS WORKERS' COMPENSATION COMMISSION 324 Spring Street, Little Rock, AR 72201 Mail: P. O. Box 950, Little Rock, AR 72203-0950 501-682-3930 / 1-800-622-4472 Ark. Code Ann. § 11-9102(9)(D), 11-9-402 Revised: 1-1-2001 A APPLICATION FOR CERTIFICATE OF NON-COVERAGE Please note prior to completing this Application: 1. Arkansas law requires workers' compensation insurance for every employment: (a) in the state in which three or more employees are regularly employed by the same employer; (b) in which two (2) or more empl oyees are employed by any person engaged in building or building repair work; (c) in which one (1) or more employees are employed by a contractor who subcontracts any part of his contract; (d) in which one (1) or more employees are employed by a subcontractor. There are some exceptions to this requirement. Contact your insurance agent or the Workers' Compensation Commission for an explanation. Exclusion of business arrangements or professions from the definition of "employee" under law does not affect the coverage rights of employees of the person(s) lis ted below. It is a felony for prime contractors to compel sole proprietors or partnerships to pay or contribute to workers' compensation in surance coverage of that sole proprietor or partnership when presented with a Certification of Non-Coverage by the sole proprietor or partnership. It is a felony for prime contractors or employers to compel sole proprietors, partnerships or "employees" to obtain a Certificate of Non-Cover age when the sole proprietor, partnership or employee does not desire to do so. Sole proprietors or partners of a partnership who devote full time to the proprietorship or partnership are presumed to be "employees" for workers' compensation purposes and subject to coverage for themselves UNLESS they obtain a Certificate of Non-Coverage. Address below must be applicant's OWN business or home address, NOT address of company to whom the applicant is contracting or for whom the applicant is doing a project. 2. 3. 4. 5. 6. 7. Company Name (list ALL names under which you yourself conduct business): Address of YOUR Company or Home: Name of Party Applying (please print; attach additional sheets if necessary): Social Security No. Social Security No. (Printed Name) Signature Date (Printed Name) 1. Yes No 2. Yes No 3. Yes No 4. If you or an y of Insurance Company: Signature Date Does the business employ others in addition to the parties listed above? Have any partners determined they wish to remain under workers' compensation coverage? Is the company or are the companies incorporated? your emp loyees are co vered und er a worke rs' compens ation policy, p lease list: Policy No.: If answers to any questions above are "yes," provide the application to your insurance agent for further processing during the writing of your workers' compensation insurance policy. The agent is to provide the following information, then forward the Application to the Arkansas Workers' Compensation Commission at the addr ess below: Agent's Name Agent's Address (City) Agent's Signature If answers to ALL questions above are "no", submit FormA to the Coverage/Compliance Section, Arkansas Workers' Compensation Commission, P.O. Box 950, Little Rock, Arkansas 72203-0950 or deliver to 324 Spring St. , Little Rock, Arkansas 72201. Your Application will be processed and action communicated back to you within ten (10) working days. SEE IMPORTANT INFORMATION ON OTHER SIDE (State) (Zip Code) A 2001 © American LegalNet, Inc. AWCC Form A (Application for Certificate of Non-Coverage) Form A is not used by corporations or corporate officers to be excluded. Exclusion of corporate officers is handled directly by the agent/carrier. If the answer is yes to Question 1 on Form A, the application for non -coverage will be rejected unless: 1. 2. The AW CC has Form I (insurance co verage car d) for the em ployment fro m a carrier; or The agent furnishes a copy of the declarations page or the National Council on Compensation Insurance application for proof of workers' co mpensatio n coverag e; or The applicant has furnished proof that coverage is not required. 3. Help with Form A is available from the AWCC C ompliance Section. General information is available from the AWCC Support Services Division. (1-800-622-4472 or 501-682-3930) Ark. Code Ann. §11 -9-106(a): Any person or entity who willfully and knowingly makes any material false statement or representation, who willfully and k nowingly omits or co nceals any m aterial informa tion, or who willfully and know ingly employs any device, scheme, or artifice for the purpose of: obtaining any benefit or payment; defeating or wrongfully increasing or wrongfully decreasing any claim for benefit or payment; or obtaining or avoiding workers' compensation coverage or avoiding payment of the prope r insurance p remium, or who aids an d abets for a ny of said purpose s, under this cha pter shall be g uilty of a Class D felony. Fifty percent (50%) of any criminal fine imposed and collec ted under .... this se ction shall be paid and allocated in accorda nce with app licable law to the Death and Perman ent Total D isability Trust Fu nd admin istered by the Workers' Compensation Commission. 2001 © American LegalNet, Inc.
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