Certification Of Acceptance {SF-7}

Form SF-7 Rev. 1-1-2001 Ark. Code Ann. §11-9-502 & AWC C Rule 28 ARKANSAS WORKERS' COMPENSATION COMMISSION SPECIAL FUNDS DIVISION 324 Spring Street, P. O. Box 950, Little Rock, AR 72203-0950 501-682-5187 / 1-866-880-8444 (Toll-free) SF-7 CERTIFICATION OF ACCEPTANCE EM PLOYEE: DPTD F ile No. AW CC File No. EMPLOYER: Carrier File No. This is an official notification that Employer/Carrier will meet its liability as defined by Ark. Code Ann. §11-9502(b) of the workers' compensation law for this claim on , provided there are no changes in the status of the beneficiary/ies. On , the Death and Permanent Total Disability Trust Fund will assume liability for the payment of benefits, provided the employer/carrier has provided the Trust Fund proof of compliance with Ark. Code Ann. §11-9-502(b)(1), with the first warrant being due two weeks after this date. Upon receipt of this Certification of Acceptance, no further AR-D forms will be required, UNLESS there is a change in the status of the beneficiary/ies. In the event of a change of status, an "amended" AR-D must be filed with the Trust Fund within 15 calendar days of any such change. Upon receipt of an "amended" AR-D, the targeted payout date will be recalculated and a new Certification of Acceptance will be prepared and sent to you. ________________________________________________ Death and Permanent Total Disability Trust Fund ***************************************** Employer/Carrier Representative Name State of County of ) ) Representative's signature SUBSCRIBED AND SWORN TO before me this ________ day of ___________________, 20_____. _______________________________________________ Notary Public My Commission Expires: Ark. Code Ann. §11-9-1 06(a): "Any pers on or enti ty wh o 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' compen sation coverage or avoiding payment of the proper insurance premium, or who aids and abets for a ny of sa id p urposes , under t his 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 Perm anen t Total Di sability Trust Fu nd ad ministered by the W orkers' C omp ensation Comm ission ." (Return this signed original form to the Trust Fund and make a copy for employer/carrier's file.) SF-7 American LegalNet, Inc. www.FormsWorkFlow.com