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Click ‘Get Form’ to open the Arkansas HS Form Sample in the editor.
Begin by filling in Item 1 with the name of your insurance company, followed by the telephone number in Item 2. Ensure that you provide a complete mailing address in Item 3, including city, state, and zip code.
For Items 5a and 5b, enter the NAIC Company number and Group number respectively. This information is crucial for identifying your insurance group.
In Item 6, input the total amount spent on accident prevention services during the current calendar year. Include all relevant expenses but exclude underwriting visit costs.
Complete Items 7a and 7b with the total amounts of workers’ compensation insurance written manual premium and direct premium for Arkansas. If necessary, attach an explanation if these amounts differ.
Fill out Items 8a and 8b regarding Field Safety Representatives and Approved Professional Safety Sources used by your company.
Provide data for Items 9 and 10 regarding on-site inspections performed and policyholders categorized by premium groups.
Finally, complete Items 11a through 11f with claims data from both the current year and previous year. Ensure accuracy as this information is vital for compliance.
Sign and date the form at the bottom to certify that all provided information is correct before submitting it to the Accident Prevention Services Section.

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What is the DHS absent parent form in Arkansas?

You can enroll in Medicaid online at Access Arkansas. Or you can visit a Department of Human Services office in your county, or call 1-800-482-8988. You can also begin the process online through Healthcare.gov if you are a non-disabled adult under age 65.

What documents are needed to apply for Medicaid in Arkansas?

What is the absent parent form for Medicaid in Arkansas? Form DCO-116, Client Statement Regarding Absent Parent, is used to collect information from the Medicaid client about an absent parent. The DCO-116 is an optional form to be used when securing absent parent information through the mail.

What documents do I need to apply for Medicaid in Arkansas?

What documents and information do you need for your Medicaid application? Your name and date of birth. Your Social Security number. Your monthly payment amounts for rent, mortgage, or utilities. Proof of citizenship or immigration status. Proof of income, like paystubs or W-2s.