|
|
|
|||||||||
|
|
|
|||||||||
|
Workers’ Compensation Forms |
|
|||||||||
|
Initial Claim Forms When a
workers’ compensation injury occurs the injured employee’s supervisor or
other person designated by the employer should make sure that the four
initial claim forms are filled out and faxed to the Public Employee Claims
Division at (501) 371-2733. Initial Employer Forms The Form
I-A1 and PECD Form 2 are to be filled out by the employer’s representative at
the time of the injury: Initial Employee Forms The Form N
and PECD Form 1 are to be filled out and signed by the employee at the time
of the injury. A copy of the front and
back of the completed Form N should be given to the injured employee at the
time he or she completes and turns in the paperwork. Please write the date the form was
delivered to the employee and the name of the person who delivered the copy
of the form to the injured employee. §
Form N Change of Work Status Form Any time
there is a change in the injured employee’s work status the employer’s
representative should fill out the Form S and fax it to the Public Employee
Claims Division at (501) 371-2733. If
this form is not promptly sent to the Public Employee Claims Division then it
may cause a delay in payment of benefits or may cause an overpayment for
which the Division will have to withhold payment from future benefits. §
Form S Mileage Form Forms to be Posted The Form H
and Form P are to be posted in a conspicuous place (such as where Fair Labor
Standards Act and Equal Employment Opportunity Notices are posted). §
Form H §
Form P |
|
|||||||||
|
|
|||||||||
|
Home I Divisions | Site Map | Contact Us |
|||||||||
