Arkansas > Workers Comp
Employers Intent To Accept Or Controvert Claim AR-2 - Arkansas
| Employers Intent To Accept Or Controvert Claim Form. This is a Arkansas form and can be used in Workers Comp . |
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ARKANSAS WORKERS' COMPENSATION COMMISSION Form AR- 2 Authority: Ark. Code Ann. §11-9-803, -810 Revised 1-1-2011 324 Spring Street, Little Rock, AR 72201 Mail: P. O. Box 950, Little Rock, AR 72203-0950 501-682-3930 / 1-800-622-4472 2 Employee SS Number Fed. Employer I.D. No. State Zip Code EMPLOYER'S INTENT TO ACCEPT OR CONTROVERT CLAIM Initial Filing AWCC File No. Amended Filing Carrier Claim No. Employee Name (Last, First, MI) Employer Name Address City Carrier or Self-Insured Name CLAIM TYPE Claims Office Name, Address, and Phone TTD - Temporary Total Disability Medical-Only (no indemnity due) PPD-Only - Permanent Partial Disability Only TPD - Temporary Partial Disability PTD - Permanent Total Disability Death Wage Statement Requested _________ (date) Salary Continuation COMPENSATION (if not applicable, skip to next section) Date of Injury City, State of Injury Dates Covered by First Check Body Part Injured Was Disability Continuous During the First 8 Days? Yes No First Day of Disability .00 Date of First Comp. Check Average Weekly Wage Wkly TTD Comp. Rate (rounded) Date Indemnity Triggered CONTROVERSION SECTION Date of injury or death: _______________ Reason for controverting claim: __________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ DEATH CASE DATA List all Dependents below: (If more space is needed, attach supplemental sheet) If no Dependents, check here: Attach Death Certificate of Deceased Employee and Birth Certificates for Dependent Children Name of dependent Date of birth Relationship to deceased Weekly benefit amount CERTIFICATION I certify that the foregoing is a complete and accurate report according to the records of the insurer pertaining to first payment, controversion and beneficiary information. I further certify that a copy of this report or equivalent information has been provided to the employee or beneficiaries. Title: Signature Printed or Typewritten Name Phone: Date If insurer is represented by an attorney, that legal representative must sign below pursuant to Ark. Code Ann. § 11-9-717 Name and Address of Attorney Signature 2 AWCC Form 2 (Employer's Intent to Accept or Controvert Claim) A form used to accept a case and repo rt paym ent or to contro vert. AWC C Form 2 also is used to amend positions taken e arlier. Help With AWCC Form 2: 1. The first payment to the emp loyee is due by the 15th day after the employer has notice of the injury or death. (Ark. Code Ann. §11-9-802) The AWCC is notified "upon making the first payment." (Ark. Code Ann. §11-9-810) A co ntroversion notice is due o n or b efore the 15 th day after notice of the death or alleged injury. (Ark. Code Ann. §11-9-803) Therefore, AW CC F orm 2 in all cases is required b y the 15 th day fro m (a) the day o f disability or (b) the day the employer is aware of the alleged incident, whichever date is later. 2. 3. 4. Be sure to include on AWC C Form 2: 5. 6. A mark in either the Initial Filing Box or A mended Filing Box. The AWCC File Number (obtained from AWCC Form A-110) and your company's file number for this case. Be sure to bear in mind: 7. 8. Form 2 is NOT interchangeable with the required written response to the 15-day letter for Form C. If respondents need ad ditional time for investigation, an extension request must be sent in before the Form 2 deadline. Using Form 2 to report that the respo ndent need s more time is invalid. If anything is written in the Controversion Section ("we are investigating"), the AWCC will consider the case controverted. If a case is opened at the AWCC on Form 1 or Form C, an AWCC Form 2 is required, ev en if the case upon investigation is determined to be a medical-only claim. 9. Questions abou t a specific F orm 2 may be answered by the AW CC Office S ervices D ivision , which processes this form. General information may be obtained from the AWC C 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 knowingly omits or conceals any material information, or who willfully and knowingly 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 proper insurance premium, or who aids and abets for any of said purposes, under this chapter shall be guilty of a Class D felony. Fifty percent (50%) of any criminal fine imposed and collected under .... this section shall be paid and allocated in accordance with applicable law to the Death and Permanent Total Disability Trust Fund administered by the Workers' Compensation Commission. Ark. Code Ann. §11-9-717: Any person or attorney signing a claim, request for benefits, controversion of benefits request for hearing or other paper of a party, certifies the action is taken after reasonable inquiry; is well grounded in fact; is warranted by existing law or a good faith argument for extension, modification or reversal of existing law; and is not interposed for any improper purpose or for delay. Violators of this provision may be subject to sanctions, which may include payment of reasonable expenses incurred by others and reasonable attorney fees for responding to the claim, request or motion, or for failure to appear at a hearing, deposition or other scheduled matter.
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