Aug.20. 2014 I615 660 6502 Alias ARKANSAS COMPENSATION COMMISSION ?mm 324 Spring Street, Little Rock, AR 72201 I Mail: PO. Box 950, Little Rook. AR 72203-0950 4 Revised: 1-1-2011 501-632-3930 I 1-800-622-4472 REPORT OF COMPENSATION OF PAYMENTS (39 Oqoq 5 AMENDED l2! ClosingRoport El Maximum Liability Report of Payment Suspension El Update Report (additional payments only) osososs spurgin David a No. Carrier Claim No. Employee Name (Last. First, Ml) Employee 33. Number C.A.A.I.R., Inc. Velma OK 73491 Employer Name I City State Zip Code Travelers Prop Can Go of America 13.0, Box 632165 Clo Travelers Franklin TN 37058-2155 Carrier or Self-Insured, Name Claims Of?ce Location (mailing address) DISABILITY INFORMATION: I I outs/2014 {ts/1312014 05/27/2o14 05/27/2014 Date of Injury Lost Day Employee Worked Dole Employa: Able to RTW Remmato-Work Date Total clays worked between injury and date able to RTW COMPENSATION INFORMATION: . COMPENSATION PAYMENTS MADE: . (9) Dolbnso Attomoy Fees (1)1113 Weeks 2_ Days 1 1. 720 - DB 0) Olhcr (Compensation Related) (2) Weeks Days BLDG (It) Hospital Expenses (3)991) Weeks Days sun (4) Weeks PTD - (13) Drugs. Medicine Weeks for Dealh (l4) Funorel Expenses (6) Lump Sum Pnym'ont . (15) Rehabilitalimr Ioint Petition Settlement Other (Expense Related) 347 . 41 Claimant Attorney Fees (1-16) GRAND TOTAL Suspension of Compensation: Compensation paid through CERTIFICATION (dale). SUSPENSION OF PAYMENTS 0F COMPENSATION Reason for Sti?ponsion; OSEO A f/ ?#7?le been provided to the employee or bene?ciaries. I certify that the farcgoing is a complete and accurate report according to the records of he insu i to a ts of compensation and sustpensions of payment Infonnotion. 1 runner cenify that a copy of on tnfonnation has Susan Boyle Susan Em Claim Professional 03/20/2014 Simemre Printed or '1 ~fajita-inert Name 2? AUG 2 0 2014 OF COMP Tirtg_ Date LIANCE orwsroN Aug.20. 2014 615 660 6502 No.3005 P. 3 'an All-S I ARKANSAS womnsi COMPENSATION COMMISSION Aulhorlly: Mk.?Code 11-9-529 Revised: 14-2001 324 Spring Street, Li tlle Rock, AR ?12201 Mail: P0. Box 950, Little Rock, AR 72203-0950 501-682-3930 I 14006224472 SUPPLEMENTAL REPORT G404035 Spurgin David . AWCC File No. I Carrier Claim No. Employee Name (Last. First. MI) - Employee 35 NumbEr C.A.A.I. ., Inc. 311mm spring AR 72764 Employer Name FEIN No. City State Zip Code Travelers Prop Gas Cu 01?. ?meric 9.0. 30:: 652165 Franklin . 4165 Denier er Self-Mum Name NAIC No. Claims Of?ce Address 1. Date ofInjury: 04! 13/2014- 2. Dale employee began losing time from work: 04 {14/2014 3. Has mnpioyce returned to work? EYes i] No If yes. give date 0512?! 2014 if employee has returned to work, is lie/she earning the same wages as before the injury? No If not, please explain: 5. Hes employee died? UYes If yes, please give date of death: ADDITIONAL INFORMATION Il'i returned to light duty on 5/27/14. He has been releaeed for thie injury with 0% PPD. CERTIFICATION I certify that the infomation above is accurate according to the recurds. susa" Boyle Susan Boyte Claim 0312mm Signature Printed or Written Name Title Date (323792 ?ll 0 May.23. 2014 615 660 6503 . - N0. 0795 P. i ARKANSAS COMPENSATION COMMISSION arm AR-Z - 324 Spring Street, Lime neck, AR 72201 2 Authorrty Ark. Code Ann Mail: P.0. Box 95 0, Little Rock, AR 72203-0950 5 11-9- 003 -aI0 501?682-3930 I LEGO-6224472 Revised 1 [-2013 qutg?s non-Lemma INTENT: TO ACCEPT 0R comovnn'r CLAIM Initial Filing amended Filing M04095 . Spurgin David .m AWCC File No, Carrier Claim No. Bnmloyee Name (Last, First, MI) Employee SS Number Inc. 108011002 Employer Name - Fed. Employer 1.13. No. - 316 Hioo . siloem Spring in 12764 Address City - State Zip Code Travelers Prep (23.3 Cu Of Amerio ?I?raVelere Workorn' Comp . (515 3 550-6316 Cjo?Travelers P.D. Ho)! 682165 Frenklin . 37063-21153 Cmier or Self-Insured Name Claims Of?ce Marne, Address, and Phone I: this a medical oniy claim? Yes No Is no: a Claim? No COMPENS 11'" ON (if not applicable, skip to next section) shoulder (5) 051231014 WY Mile/2014 Dale of First Comp. Check Dates Covered by Firs: Check Body Part Injufcd Firetlnoy orDieahilin . Wee Disability Continuous I $420.00 $200.00. Du?nedwFinIBDm? I Average Weekly Wage I ?0&1mi Comp. Ratatmundcd} Date indemnity'TI-iggered STATEMENT OF POSITION Date of? Injury 0; death: City, State of? Injury mm State your position. If controver?ng, more the grounds therefore: Wage information received- yet. DEATH cesn DATA List all Dependents below: (Enron! space is needed, arrach suppimenmi sheer) If no Dependents, cheat here: Armch Death Certi?cate ofDeceaeed Em layers and HM: Certi?camfor Dependent Children Heme of dependent Date ofbirth Relationship to deceased I Weekly bene?t amount CERTIFICATION I certify that the feregoing' 18 a complete and accurate report according to the records of the Immr peneining In ?rst payment. controvereion and beneficiary informanon I ?IrBheLcerIify that II copy ofrhis report or equivalem information he: been provided to the employee I Wig/7 Schuyler Lanniey Tm?: Clam Prafeaamn? 05/23/2014 mind I Primed OIvarinenName Phone: (615)660-6316 um If insurer is represented by an memey, that legal rapnesentativo must Sign below pursuant to Ark. Code Ann. - Name and Address of Attorney Ta memm I - my ii MAY 23 new cmee 1m: OPE ARKANSAS .. w. .. A. .. - I Carrier urge got notgfieg of QLQM until 5mm May 22 10M 337m 615 660 6502 COMPENSATION- FIRST REPORT OF INJURY grimy "no sum- syrina um mem mm. mum", mm. iauum'mmn P)2I=me mam mm mmunmn 5m mason way can Cu 0! mm mm." Mg CH of mm: A La. Box sum 'nl amt-ms wax/2m Schuyler Wm w. an <. RE: FILE: G404095 EMPLOYEE: DAVE) B. SPURGIN EMPLOYER: A A I INC Travelers Prop Cas - America DATE OF INJURY: 4/13/2014 CARRIER FILE 101CBEZX03 48 EMAIL DATE: 8/20/2014 FORM AR-4 FILED ON 8/20/2014 FORM AR-4 NOTICE OF RECEIPT If no error code is shown immediately below this paragraph, the has been accepted, processed and ?led. If however, any - error COde is shown, please make the necessary correction(s) and resubmit within ?ve business days of this notice. Until each - . error is corrected, the All-4 ?ling remains in reject status. ERROR No Error, Form 4 Accepted 001 - Diagnosis 013 - PPD Underpayment 002 Permanent Impairment Rating 014 Return to Work Date/Date Able to Return 003 - Final Medical/Release needed 015 - Lump Sum Incorrect or Form IL required 004 Submit separate AR-4. for each claim 016 - Joint Petition Amount/MSA (line 7) 005 - File AR-2 - 017 - Claimant Attorney Fees . an Animated . .. . . - 007 File a Form 5 (?Employer Suppiernent) 019 Medical Payment Amounts 008 Date of Injury I 020 a Grand Total is incorrect 009 - Incorrect "Disability Information" - 021 - AR-4 Certi?cation Signature missing 010 Date TTD Paid through 022 Include Child Support (line 7) 011 - Last Day Employee Worked 023 - TTD Overpayment 012 - TTD Underpayment 024 - PPD Overpayment 025 - Other Error If you have any questions regarding completing or ?ling an AR-4, please email Coti McIntyre-Patrick at Designated Claim Of?ce Reporting Claim Of?ce Company Name Travelers Insurance Company Company Name Mailing Address 6640 Carothers Parkwayr Mailing Address Suite 300 Franklin. TN 37067-6305 Co ntaot(M r/Ms) Direct Dial# Extension# Contact Fax# Toll Free# Contact E-mail LaDonna Thurston (615) 660-6306 (877) 786-5582 (800) 342-4064 tthursto@travelers.com Contact(Mr/Ms) Direct Dial# Extension# Contact Fax# Toll Free# Contact E-mail RE: FILE: - (3404095 EMAIL DATE: 5l23/2014 EMPLOYEE: - DAVID B. SPURGIN EMPLOYER: . A A INC Travelers Prop Cas - America DATE OF INJURY: 411312014 CARRIER IOICBEZXO348 FORM AR-2 FILED ON 5/23/2014 FORM AR-2 DUE DATE 6/10l2014' FORM AR-2 NOTICE OF RECEIPT If no error code is shown immediately below this paragraph, the AR- 2 has been accepted,_ processed and filed. If, however, any error code' Is shown, please make the necessary correction(s) and resubmit within five business days of this notice. Until each error is corrected, the AR-2 remains in reject status. ERROR No Error, Form 2 Accepted 001 - Incorrect Compensation Rate 002 - AR-2 Certi?cation Signature missing 003 - Dates covered by ?rst check 004 - Date of Injury rounded to nearest dollar 005 - Date disability began information 006 Date of 1st comp check 00? - Employee average weekly wage 008 - Weekly rate of compensation 009 First pay date precedes disability date 010 - Weekly TTD Comp rate must be 011 H- For? all Death Cases, provide dependent 012 Wage statement is required 013 - Other Error If you have any questions regarding completing or ?ling an AR-2, please email Linda Lewis at Ilewis@awcc.state.ar.us. Designated Claim Of?ce Company Name Travelers Insurance Company Mailing Address 6640 Carothers Parkway Franklin. TN 37067-6305 Contact(Mr/Ms) LaDonna Thurston Direct Dial# (615: 660-6306 Extension# Reporting Claim Of?ce Company Name Mailing Address Direct Dial# Extension# Contact Fax# Contact Fax# (8771 786-5582 Toll Free# Toll Free# 1800) 342?4064 Contact E-mail I Contact E-mail lthursto@travelers.com DAVID B. SPURGIN 0 BOX 14 VELMA, OK 73 491 Date: 05/23/2014 AWCC File G404095 DAVID B. SPURGIN. vs. A A I INC Date of Injury: 4/13/2014 - TO THE CLAIMANT: - The Insurance Carrier/TPA/Self-Insured has ?led with the Arkansas Workers? - Compensation Commission an AR-2 stating their position on your claim for Workers' Compensation bene?ts. If you have not already been contactedby a representative of the insurance carrier/self?insured, you may I contact the insurance adjuster whose name and phone number appear on the bottom of the enclosed Form 2 before beginning any medical procedures. If you have any question(s) about your rights and/or the proceedings available to you and are represented by an attorney, please contact your attorney for legal or procedural advice. If, however, you are not represented by an attorney, you may contact the Arkansas Workers' Compensation Commission Legal Advisor Division free of charge. A legal advisor may be reached at 501-682-3 93 0, or if calling from outside I of Pulaski COunty, 1?800?250?25 1 1. Legal Advisor Division Enclosure Original Letters to: