Hs-32-C, Notification Of Potential Data Error

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ARKANSAS WORKERS’ COMPENSATION COMMISSION
Form H S-32-C
HS-
HEALTH & SAFETY DIVISION
324 Spring Street, Little Rock, AR 72201
Ark. Code Ann.
32-C
Mail: P. O. Box 950, Little Rock, AR 72203-0950
§11-9-409 &
501-682-3930 / 1-800-622-4472
AWCC R ule 32
Rev. 1-1-2001
Notification of Potential Data Error
If you question the information used to ide ntify you r comp any, com plete this workshee t and return it to the Ark ansas Wo rkers’
Compensation Com mission, H ealth and Safety D ivision. Within 15 days of receipt of this letter, the completed worksheet and
supporting documents should be mailed to:
Attn: Rule 32 W orksheets
Arkansas Workers’ Compensation Commission
Health and Safety Division
P.O. Box 950
Little Rock, AR 72203-0950
Date: ___________
AWCC File No.: 32-_______________
Company Name: ____________________________________________________________ FEIN: ____________________
dba Name (if applicable):_______________________________________________________________________________
Address: ____________________________________________________________________________________________
Contact: (Name) __________________________________________ (Title) ______________________________________
Telephone no: __________________________________
Fax no.: _____________________________________
e-Mail: _____________________________________________________________________________________________
Insurance Carrier: ________________________________
Policy Date: ________________________
Check the area(s) where you question the data used. Attach copies of all required suppor ting docu ments to this worksheet and
return to the add ress abov e. No cha nges in th e hazar d index c alculatio n can be made until all required information is
received.
Required Supporting D ocuments
Potential Data Error
Incorrect number of employees
Four quarterly “Contribution and Wage Reports” (Form ESD-ARK-209B)
submitted to the Arkansas Emp loyment Security Division for last year.
Incorrect number of indemnity cases
Number of cases believed to be correct; documentation showing any cases that
were controverted and found not to be compensable.
Note: all indem nity cases are include d in the calculation u nless they are
successfully controverted.
Incorrect SIC Code
Notify ESD, tel.: (501) 682-3194 of correct SIC and submit verification letter
received from ESD.
HS 32-C

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