Notification Of Potential Data Error {HS-32-C}

ARKANSAS WORKERS' COMPENSATION COMMISSION Form H S-32-C HEALTH & SAFETY DIVISION Ark. Code Ann. §11-9-409 & AWCC R ule 32 Rev. 1-1-2001 324 Spring Street, Little Rock, AR 72201 Mail: P. O. Box 950, Little Rock, AR 72203-0950 501-682-3930 / 1-800-622-4472 HS32-C 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. 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. Notify ESD, tel.: (501) 682-3194 of correct SIC and submit verification letter received from ESD. HS 32-C Incorrect number of indemnity cases Incorrect SIC Code American LegalNet, Inc. www.FormsWorkflow.com