Get Form O - Arkansas Workers' Compensation Commission - Awcc State Ar

Filling out the Form O for the Arkansas Workers’ Compensation Commission is an essential step for insurance carriers and self-insured employers. This guide provides clear, step-by-step instructions to assist users in successfully completing the form online.

Follow the steps to efficiently fill out the Form O.

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. Begin by filling out the 'Insurance Carrier' or 'Self-Insured Employer or Group' section. Indicate the NAIC Company Number and NAIC Group Number if applicable.
3. In the 'Company Name' field, enter the full legal name of the insurance carrier or self-insured employer/group. Input the Federal Employer Identification Number (FEIN) in the designated area.
4. For the 'Claim Office' section, specify whether the claims are self-administered or handled by a third-party administrator (TPA) by marking the appropriate box.
5. Complete the contact details for the claim office, including the company name, mailing address, direct dial phone number, and fax number.
6. If your organization is self-administered, provide the contact name, phone number, toll-free number, and email address of the person responsible for claims.
7. Fill in the 'Medical Billing' section with the necessary billing contact information, including the company name, mailing address, direct dial phone number, billing fax number, toll-free number, and billing email address.
8. Proceed to the 'Administrator' section by entering the required details for the administrator responsible for compliance and claims.
9. Include information regarding the underwriting contact in the corresponding section, including contact name, phone number, and email address.
10. In the designated signature area, print the name of the employee completing the form, provide their title, phone number, and the date of completion, followed by an authentic signature.
11. Once the form is fully completed, users can save the changes, download the document for their records, print it for submission, or share it as needed.

Complete your Form O online today to ensure compliance with Arkansas Workers’ Compensation requirements.