State of Arkansas Forms in Word

Arkansas Workers’ Compensation Forms in Microsoft Word

Form No.

Form Title

Price

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Claims Adjusting forms

Form 1&(4-Sided Form)

First Report of Injury or Illness

$12.99

Form 2&(2-Sided Form)

Employer’s Intent to Accept or Controvert

$12.99

Form 3&(2-Sided Form)

Physician’s Report

$12.99

Form 4&(2-Sided Form)

Report of Compensation Paid/Suspension Report

$12.99

Form A&(3-Sided Form)

Instructions&on Fee and Notary StatementApplication&for Certificate of Non-Coverage (2-Sided)Required&Notary Statement

$12.99

Form C&(2-Sided Form)

Claim for Compensation

$12.99

Spanish Form C&(2-Sided Form)

Claim for Compensation

$12.99

Form D&(2-Sided Form)

Death/PTD Acceptance/Update

$12.99

Form H&(2-Sided Form)

Health Notice for Managed Care

$12.99

Form L&(2-Sided Form)

Lump Sum Request/Respondent’s Position

$12.99

Form M&(2-Sided Form)

Monthly Medical-Only Injury Data

$12.99

Form N&(2-Sided Form)

Notice to Employer/Notice to Employee

$12.99

Spanish Form N&(2-Sided)

Notice to Employer/Notice to Employee

$12.99

Form O&(One-Sided Form)

Claim Office / Administrator / Underwriter Designation Form

$12.99

Form P&(2-Sided Form)

Poster of Instructions

$12.99

Spanish Form P&(2-Sided)

Poster of Instructions

$12.99

Form R&(One-Sided Form)

Report of Mediation Conference

$12.99

Form S&(2-Sided Form)

Supplemental Report

$12.99

Form V&(2-Sided Form)

Verification of PTD

$12.99

Form W&(2-Sided Form)

Wage Statement

$12.99

Health and Safety Division forms

Form HS-31-A&(2-Sided Form)

APSS/FSR Application

$12.99

Form HS-31-C&(2-Sided Form)

Accident Prevention Services Annual Report

$12.99

Form HS-31-D&(2-Sided Form)

Accident Prevention Services Worksheet

$12.99

Form HS-31-E&(One-Sided Form)

List of FSR/APSS

$12.99

Form HS-32-A&(One-Sided Form)

Hazard Survey Report

$12.99

Form HS-32-B&(One-Sided Form)

Health & Safety Plan Cover Sheet

$12.99

Form HS-32-C&(One-Sided Form)

Notification of Potential Data Error

$12.99

Form HS-36-A&(2-Sided Form)

Voluntary Drug-Free Workplace Program Application

$12.99

Form HS-36-B&(One-Sided Form)

Voluntary Drug-Free Workplace Program Annual Insurance Carrier Report

$12.99

Self-Insurance Division forms

Form SI-1&(4-Sided Form)

Individual Self-Insurer Application

$12.99

Form SI-11&(3-Sided Form)

Group Self-Insurance Application

$12.99

Form SI-12&(3-Sided Form)

Application for Membership in a Group

$12.99

Third-Party Administration form

Form TPA&(3-Sided Form)

Third-Party Administrator Application / Registration

$12.99

Self-Insurance Division forms

Form SI-7&(One-Sided Form)

Loss Summary Data Report

$12.99

Form SI-7-A&(One-Sided Form)

Loss Summary Data Report – Itemized Listing

$12.99

Special Funds Division forms

Form SF-1&(One-Sided Form)

Claimant Information Update/Change of Address

$12.99

Form SF-2&(One-Sided Form)

Guardianship Affidavit (Court – Appointed, Non-Minor)

$12.99

Form SF-3&(One-Sided Form)

Power of Attorney Notice & Affidavit

$12.99

Form SF-4&(One-Sided Form)

Surviving Spouse Notice & Affidavit

$12.99

Form SF-5&(2-Sided Form)

Guardian’s Affidavit – Dependent Child(ren)

$12.99

Form SF-6&(One-Sided Form)

Affidavit for Dependents Other Than Spouse or Child

$12.99

Form SF-7&(One-Sided Form)

Certification of Acceptance

$12.99