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:

• Form I-A1
• PECD Form 2

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
• PECD Form 1  ( Word)   ( PDF)

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

• 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