A
Form AR-A
Ark. Code Ann. §
11-9-102(9)(D),
11-9-402
Revised 1-1-2008
ARKANSAS WORKERS’ COMPENSATION COMMISSION
324 Spring Street, Little Rock, AR 72201
Mail: P.O. Box 950, Little Rock, AR 72203-0950
501-682-3930/1-800-622-4472
Be sure to include: Application, Notarized Certificate, and
Check or Money Order for $50 made payable to
Arkansas Workers’ Compensation Commission
APPLICATION FOR CERTIFICATE OF NON-COVERAGE
Please note prior to completing this Application:
1. Arkansas law generally requires workers’ compensation insurance for every employment:
(a) in which three (3) or more employees are employed by the same employer;
(b) in which two (2) or more employees are engaged in building or building repair work;
(c) in which one (1) or more employee is employed by a contractor who subcontracts any part of his contract;
(d) in which one (1) or more employee is employed by a subcontractor.
2. In order to arrive at the above number, employee is defined to include, but is not limited to, an owner, a sole proprietor, a partner or
partners who devote full-time to the partnership, a full-time employee, a part-time employee, and a volunteer.
3. It is a felony for any employer or contractor to compel any employee or sub-subcontractor to pay for, or
contribute to, workers’ compensation insurance coverage.
4 It is a felony for any employer or contractor to compel any employee or sub-contractor to obtain a
Certificate of Non-Coverage.
5. Address below must be the applicant’s OWN business or home address, NOT address of company to whom the applicant is contracting
or for whom the applicant is doing a project.
6. Any questions or comments may be referred to your workers’ compensation insurance agent or the Arkansas
Workers’ Compensation Commission.
Applicant Information (please print):
- -
(Printed Name) Social Security No. Signature Date
Company Name (list ALL names under which you yourself conduct business):
Business Address:
1. G Yes G No Does the business employ others in addition to the parties listed above?
2. G Yes G No Is the company or companies incorporated?
3. If you or any of your employees are covered under a workers’ compensation policy, please list:
Insurance Company:
Policy No.:
If answers to any questions above are “yes,” provide the application to your insurance agent for further processing during the writing of your
workers’ compensation insurance policy. The agent is to provide the following information, then forward the Application to the Arkansas W orkers’
Compensation Commission at the address below:
Agent’s Name
Agent’s Address
(City) (State) (Zip Code)
Agent’s Signature
If answers to ALL questions above are “no”, submit Form A to the Coverage/Compliance Section, Arkansas Workers’ Compensation, P.O. Box
950, Little Rock, Arkansas 72203-0950 or deliver to 324 Spring St., Little Rock, Arkansas 72201. Your Application will be processed and action
communicated back to you within ten (10) working days.
SEE IMPORTANT INFORMATION ON OTHER SIDE
