top of page

Authorized Forms

Note:  All application forms in this page are in PDF form (fillable)

Authorizing of Medical Treatments by the Employer

Injury Reporting Notification (for Employer)

Injury Reporting Notification (for injured Employee)

Filing an Injury or Disability Claim before the Commission

Employer's Official Response on the Claim Filed

Filing a Death Benefit Claim before the Commission

Employer's Official Response on Death Benefit Claim Filed

Requesting of a Hearing Order [A.S.C.A. 32.0635]

Notice to Dispute and Controvert Right of Compensation on Claim

Filing a Payment Claim for Legal Fees & Other Claim Services before the Commission

Filing a Complaint Against an Exempted Employer before the Commission

Permanent Impairment Evaluation (for the Examining Doctor)

Employee to Request a Secondary Medical Opinion on Disability before the Commission

Examination to Determine Employee Ability to Resume and Return to Work

Payment Issuance - Notice of First, Suspension, and Final Payment

Petition for a Lump Sum Reimbursement under A.S.C.A. 32.0666

Petition for a Penalty Award on a Late Payment

Authorization for a Carrier to Provide WC Insurance under the ASWCA

Application for Self-Insurance

Notice to Cancel Insurance Policy (for Insurance Carriers)

Clearance to File a Compliance Certificate

Request for Verification Letter

bottom of page