Notice Of Claimant Information Update Change Of Address {SF-1}

Form SF-1 Rev. 1-1-2001 Autho rity: Ark. Code Ann. §11-9-205 ARKANSAS WORKERS' COMPENSATION COMMISSION SPECIAL FUNDS DIVISION 324 Spring Street, P. O. Box 950, Little Rock, AR 72203-0950 501-682-5187 / 1-866-880-8444 (Toll-free) SF-1 NOTICE OF CLAIMANT INFORMATION UPDATE / CHANGE OF ADDRESS AWCC File No. Claimant: I have a change of (check all that apply): G mailing address, G residence address, G telephone number(s), G emergency contact person, to be effective on _________________________________, 2________. ****************************************************************************************** Old Address: City Home Tel. (AC) State Day/Work Tel. (AC) ZIP New Address: Mail address (if different) City Home Tel. (AC) State Day/Work Tel.(AC) ZIP Emergency Contact: Name Home Tel.(AC) Address City State Relationship Day/Work Tel.(AC) ZIP Claimant signature Date Ark. Code Ann. §11-9-1 06(a): "Any pers on or enti ty wh o willfu lly and know ingly makes any material false s tatemen t or repres enta tion, who willfu lly and know ingly omits or con ceals any m ateri al informa tion, or who w illfully an d kn owin gly em ploys any d evice, schem e, or artifice for th e pu rpos e of: obtaining any benefit or payment; defeatin g or w rongfully increasing or w rongfully decreasing an y claim for benefit or payment; or obtaining or avoid ing workers' comp ensation coverage or avoiding payme nt of the proper insu rance prem ium, or who a ids and ab ets for any of said purp oses, under th is chapter sha ll be guilty of a Class D felony. Fifty percent (50%) of any criminal fine imposed and c ollected 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 Workers' Compensation Commission." SF-1 American LegalNet, Inc. www.FormsWorkFlow.com