Form O, Claim Office Designation Form
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1
2ARKANSAS WORKERS’ COMPENSATION COMMISSION
Form O
Eff 1/01/2013
O
324 Spring Street, Little Rock, AR 72201
Mail: P. O. Box 950, Little Rock, AR 72203-0950
Rule 099.29
501-682-2783 / 1-800-622-4472
CLAIM OFFICE / MEDICAL BILLING /ADMINISTRATOR / UNDERWRITER
Designation Form
Please see the reverse side of this form for completion instructions
Insurance Carriers - Please complete the following
This form is being filed for:
NAIC Company Number
NAIC Group Number
An Insurance Carrier
A Self-Insured Employer or Group
Company Name
FEIN
(full legal)
Medical Billing:
Claim Office:
Claims are:
Self-Administered
Handled by a TPA
Company Name
______________________________
Mailing Address
______________________________
Company Name
_____________________________
______________________________
Mailing Address
_____________________________
Direct Dial Phone #
______________________________
______________________________
Billing Fax #
______________________________
Complete the following only if self-administered:
Toll Free #
______________________________
Contact Name (Mr/Ms.) ______________________________
Billing E-mail
______________________________
Direct Dial Phone #
______________________________
Contact Fax #
______________________________
Toll Free #
______________________________
Contact E-mail
______________________________
Underwriting:
Administrator:
Company Name
______________________________
Company Name
______________________________
Mailing Address
______________________________
Mailing Address
______________________________
_______________________________
_______________________________
Contact Name (Mr/Ms.) ______________________________
Contact Name (Mr/Ms.) ______________________________
Direct Dial Phone #
______________________________
Direct Dial Phone #
______________________________
Extension #
______________________________
Extension #
______________________________
Contact Fax #
______________________________
Contact Fax #
______________________________
Toll Free #
______________________________
Toll Free #
______________________________
Contact E-mail
______________________________
Contact E-mail
______________________________
I, ____________________________________________(printed name), as an employee of the above carrier/self-insured employer (or its parent
company), make the above designations in compliance with Commission Rule 099.29. Further, we agree to promptly notify the Commission of
any changes to the above designations by re-completing and submitting this form.
Phone
Signature
Title
Date
Form O (Eff 10/1/12)
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Parent category: Legal