Instruction Sheet 

To report a workplace injury claim for state government employees - Company Nurse

Workers’ Compensation Procedures for Arkansas State Government Employees

Initial Reporting of Claim:

When an Arkansas state government employee is involved in an incident while performing employment services which might have injured him or her, the incident should be immediately reported to the employee’s direct supervisor.

  1. If the employee is in need of emergency care for a life-threatening emergency, call 911 and obtain immediate medical care.  The supervisor should call the Company Nurse® toll free number (which is available 24 hours a day, 7 days a week) to report the claim and complete an incident report form after ensuring the employee receives the needed emergency medical care.
  2. If the employee does not believe that he or she will need medical care, the employee should immediately complete an incident report form.  If the employee later decides that he or she needs medical treatment then he or she should call the Company Nurse® toll free number (which is available 24 hours a day, 7 days a week) to report the claim and talk to a registered nurse.  The employee will be directed to a medical clinic that will see him or her on short notice.
  3. If the employee believes that he or she needs medical care at the time of the incident then he or she should call the Company Nurse® toll free number (which is available 24 hours a day, 7 days a week) to report the claim and speak to a registered nurse.  The employee will be directed to a medical clinic that will see him or her on short notice.

The Public Employee Claims Division of the Arkansas Insurance Department directs medical care for workers’ compensation injuries suffered by Arkansas state government employees pursuant to Ark. Code §11-9-508 and §11-9-514.

IMPORTANT:  Employees receiving medical care for injuries which are not life-threatening prior to reporting an injury may have payment for those services denied pursuant to Ark. Code 11-9-701.

Once the employee reports the injury to Company Nurse®, a copy of the claim will be sent to the human resources personnel at the agency or college or university within a few minutes of the call.

The Agency’s Human Resources Personnel Should:

  1. Review the Form I-A1, Form N, PECD Form 1, with the injured employee, have the employee make any corrections, and sign and date the forms.  The employee should sign the front and back of the Form N; and
  2. Provide a copy of the front and back of the signed Form N and a Temporary Prescription Card to the employee; and
  3. Fax the signed claim forms to the Public Employee Claims Division

Forms:

 Initial Claim Forms:

When a workers’ compensation injury occurs the injured employee’s supervisor or other designated by the employer should make sure that the four initial claim forms are filled out and faxed to PECD at (501) 371-2733.

Employer Forms:

To be filled out by the employer’s representative at the time of the injury:

Form IA-1

PECDForm 2

Employee Forms:

To be filled out and signed by the employee at the time of 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. The front and back side of the Form N and the Form AR-N Employee Acknowledgement Form should be completed and signed by the employee. A copy of both forms (front and back of Form N) should be given to the employee at the time he or she completes and turns in the paperwork.

Form N  Medical Release        Form AR-N Employee Acknowedgement

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 PECD. If this form is not promptly submitted, it may cause a delay in payment or an overpayment of benefits.

Form S

Mileage:  

Mileage Form

Forms to Post:

Form H and Form P art 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