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Notice Of Claimant Information Update Change Of Address SF-1 - Arkansas

Notice Of Claimant Information Update Change Of Address Form. This is a Arkansas form and can be used in Workers Comp .
 Fillable pdf Last Modified 10/11/2006
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Form SF-1 Rev. 1-1-2001 Authority: Ark. Code Ann. §11-9-205 ARKANSAS WORKERS' COMPENSATION COMMISSION SPECIAL FUNDS DIVISION 1515 West Seventh Street, Suite 219, Little Rock, AR 72201 501-682-5187 / 1-800-622-4472 (Toll-free) SF-1 NOTICE OF CLAIMANT INFORMATION UPDATE / CHANGE OF ADDRESS AWCC File No. Claimant: I have a change of (check all that apply): G mailing address, G residence address, G telephone number(s), G emergency contact person, to be effective on _________________________________, 2________. ****************************************************************************************** Old Address: City Home Tel. (AC) State Day/Work Tel. (AC) ZIP New Address: Mail address (if different) City Home Tel. (AC) State Day/Work Tel.(AC) ZIP Emergency Contact: Name Home Tel.(AC) Address City State Relationship Day/Work Tel.(AC) ZIP Claimant signature Date Ark. Code Ann. §11-9-106(a): "Any pers on or ent ity who w illfully and kn owingly makes any material false state ment or represe ntation , who wi llfully and kn owingly omits or conce als any m aterial in formation , or who w illfully and kn owingly em ploys any d evice, sc heme, o r artifice for the pur pose of: obtaining any benefit or payment; defeatin g or wron gfully incre asing or w rongfully decreasing any claim for benefit or payment; or obtaining or avoiding workers' com pensation coverage or avoiding payment of the proper insu rance premium, or who a ids and abets for any of said purposes, under th is 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." SF-1 2001 © American LegalNet, Inc.
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