State of Arkansas Forms in Word
Arkansas Workers’ Compensation Forms in Microsoft Word
| Form No. |
Form Title |
Price |
Buy Now |
| 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 |