Form AR-A
Ark. Code Ann. §
Revised 1-1-2008
324 Spring Street, Little Rock, AR 72201
Mail: P.O. Box 950, Little Rock, AR 72203-0950
Be sure to include: Application, Notarized Certificate, and
Check or Money Order for $50 made payable to
Arkansas Workers’ Compensation Commission
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.
Assistance with Form A and/or the accompanying affidavit is available from the AWCC Compliance Section. General information
is available from the AWCC at 800-622-4472 outside of Pulaski County, or 501-682-3930.
Ark. Code Ann. §11-9-106(a): “Any person or entity who willfully and knowingly makes any material false statement or representation, who
willfully and knowingly omits or conceals any material information, or who willingly and knowingly employs any device, scheme, or artifice
for the purpose of : obtaining any benefit or payment; defeating or wrongfully increasing or wrongfully decreasing any claim for benefit or
payment; or obtaining or avoiding workers’ compensation coverage or avoiding payment of the proper insurance premium, or who aids and
abets for any of said purposes, under this chapter shall be guilty of a Class D felony. Fifty percent (50%) of any criminal fine imposed and
collected under ... this section shall be paid and allocated in accordance with applicable law to the Death and Permanent Total Disability Trust
Fund administered by the W orkers’ Compensation Commission.”
(Application for Certificate of Non-Coverage)
Form A is not used for exclusion from a workers’ compensation policy by corporations or corporate officers, sole proprietors, partners of a
partnership, members of a limited liability company, members of a professional association, or a self-employed employer who is not a subcontractor
and who owns and operates his or her own business. Exclusions of corporate officers from coverage is handled directly by the agent/carrier.
If the answer is yes to Question 1 on Form A, the application for non-coverage will be rejected unless:
1. The agent furnishes a copy of the declarations page or the National Council on Compensation Insurance application for proof of
workers’ compensation coverage; or
2. The applicant has furnished proof that coverage is not required.
(Revised 1-1-2008)