FIRST REPORT OF INJURY OR ILLNESS
RECEIVED BY
CLAIMS-HANDLING ENTITY
SENT TO DIVISION DATE DIVISION RECEIVED DATE
FLORIDA DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
For assistance call 1-800-342-1741
or contact your local EAO Office
Report all deaths within 24 hours 1-800-219-8953 or (850) 922-8953
PLEASE PRINT OR TYPE EMPLOYEE INFORMATION
NAME (First, Middle, Last)
Social Security Number Date of Accident (Month-Day-Year) Time of Accident
AM PM
HOME ADDRESS
Street/Apt #: _________________________________________________________
City: _________________________ State: _______________ Zip: ______________
EMPLOYEE'S DESCRIPTION OF ACCIDENT (Include Cause of Injury)
TELEPHONE Area Code Number
OCCUPATION
INJURY/ILLNESS THAT OCCURRED PART OF BODY AFFECTED
DATE OF BIRTH
_________ / _________ / _________
SEX
M F
EMPLOYER INFORMATION
COMPANY NAME: ___________________________________________________
D. B. A.: ____________________________________________________________
FEDERAL I.D. NUMBER (FEIN)
DATE FIRST REPORTED (Month/Day/Year)
Street: _____________________________________________________________
City: _________________________ State: _______________ Zip: ______________
NATURE OF BUSINESS
POLICY/MEMBER NUMBER
TELEPHONE Area Code Number DATE EMPLOYED
_________ / _________ / _________
PAID FOR DATE OF INJURY
YES NO
EMPLOYER'S LOCATION ADDRESS (If different)
Street: _____________________________________________________________
LAST DATE EMPLOYEE WORKED
_________ / _________ / _________
WILL YOU CONTINUE TO PAY WAGES INSTEAD OF
WORKERS' COMP?
YES
City: ________________________ State: _______________ Zip: ______________
LOCATION # (If applicable) ____________________________________________
RETURNED TO WORK
YES NO
IF YES, GIVE DATE
_________ / _________ / _________
LAST DAY WAGES WILL BE PAID INSTEAD OF
WORKERS' COMP
_________ / _________ / _________
PLACE OF ACCIDENT (Street, City, State, Zip)
Street: _____________________________________________________________
DATE OF DEATH (If applicable)
_________ / _________ / _________
RATE OF PAY
$ _________________ PER
HR WK
DAY MO
City: _________________________ State: _______________ Zip: ______________
COUNTY OF ACCIDENT ______________________________________________
AGREE WITH DESCRIPTION OF ACCIDENT?
YES NO
Number of hours per day
Number of hours per week
Number of days per week
______________________
______________________
______________________
Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program, files a
statement of claim containing any false or misleading information commits insurance fraud, punishable as provided in s. 817.234. Section 440.105(7),
F.S.
I have reviewed, understand and acknowledge the above statement.
__________________________________________________________________ _______________________________________________
EMPLOYEE SIGNATURE (If available to sign) DATE
__________________________________________________________________ _______________________________________________
EMPLOYER SIGNATURE DATE
NAME, ADDRESS AND TELEPHONE
OF PHYSICIAN OR HOSPITAL
AUTHORIZED BY EMPLOYER
YES NO
CLAIMS-HANDLING ENTITY INFORMATION
1(a) Denied Case - DWC-12, Notice of Denial Attached 2. Medical Only which became Lost Time Case (Complete all required information in #3)
1(b) Indemnity Only Denied Case - DWC-12, Notice of Denial Attached Employee’s 8
TH
Day of Disability _________ / _________ / _________
Entity’s Knowledge of 8
TH
Day of Disability _________ /_________ / _________
3. Lost Time Case - 1st day of disability _________ / _________ / _________ Full Salary in lieu of comp? YES Full Salary End Date ________/ ________ / ________
Date First Payment Mailed _________ / _________ / _________ AWW ____________________________ Comp Rate ____________________________
T.T. T.T. - 80% T.P. I.B. P.T. DEATH SETTLEMENT ONLY
Penalty Amount Paid in 1
st
Payment $___________ Interest Amount Paid in 1
st
Payment $__________
REMARKS:
INSURER NAME
CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE
INSURER CODE #
EMPLOYEE'S CLASS CODE EMPLOYER'S NAICS CODE
SERVICE CO/TPA CODE #
CLAIMS-HANDLING ENTITY FILE #
Form DFS-F2-DWC-1 (08/2004)
