Arkansas Report of Payment (Form 4) from LaborLawCenter.com

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Arkansas Report of Payment (Form 4)

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Product Description

Final Report is due within 30 days of the last payment. ACA § 11-9-810(b)(1).
Form 4 must provide the AWCC file number.
Carriers must list their NAIC number.
Employers must list their FEIN.
Form 4 is for all end-of-payment reports, i.e.:
1. The Suspension of Benefits; reason for suspension must be given.
2. The closing of an MO opened by a respondent on Form 1 or a claimant on Form C.
3. The Final Report of an indemnity case, detailing all payments. Forms 1, 2, and 3 (or narrative medical report) are required for these cases.
4. Maximum liability being reached in cases involving death or PTD (both the Compensation Section and the Suspension of Payments Section are completed). The box for Death/PTD Maximum Liability must be marked.
5. Cases with a Lump Sum Payment or a Joint Petition Settlement require Form 4. *Other on Line (10) of the Compensation Information Section includes benefits not listed elsewhere, such as interest and penalties.
*Other on Line(16) includes court reporter fees and mileage reimbursement.

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