FIRST REPORT OF INJURY OR ILLNESS
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
RECEIVED BY CLAIMS-HANDLING ENTITY
SENT TO DIVISION DATE
DIVISION RECEIVED DATE
PLEASE PRINT OR TYPE NAME (First, Middle, Last)
EMPLOYEE INFORMATION Social Security Number
Date of Accident (Month-Day-Year)
Time of Accident AM PM
HOME ADDRESS Street/Apt #: _________________________________________________________ City: _________________________ State: _______________ Zip: ______________ TELEPHONE Area Code Number
EMPLOYEE'S DESCRIPTION OF ACCIDENT (Include Cause of Injury)
OCCUPATION
INJURY/ILLNESS THAT OCCURRED
PART OF BODY AFFECTED
DATE OF BIRTH _________ / _________ / _________
SEX M F EMPLOYER INFORMATION FEDERAL I.D. NUMBER (FEIN) DATE FIRST REPORTED (Month/Day/Year)
COMPANY NAME: ___________________________________________________ D. B. A.: ____________________________________________________________ NATURE OF BUSINESS Street: _____________________________________________________________ City: _________________________ State: _______________ Zip: ______________ TELEPHONE Area Code Number DATE EMPLOYED _________ / _________ / _________ LAST DATE EMPLOYEE WORKED EMPLOYER'S LOCATION ADDRESS (If different) _________ / _________ / _________ Street: _____________________________________________________________ City: ________________________ State: _______________ Zip: ______________ LOCATION # (If applicable) ____________________________________________ RETURNED TO WORK IF YES, GIVE DATE YES NO LAST DAY WAGES WILL BE PAID INSTEAD OF WORKERS' COMP _________ / _________ / _________ RATE OF PAY $ _________________ PER DAY AGREE WITH DESCRIPTION OF ACCIDENT? City: _________________________ State: _______________ Zip: ______________ COUNTY 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) __________________________________________________________________ EMPLOYER SIGNATURE _______________________________________________ DATE _______________________________________________ DATE CLAIMS-HANDLING ENTITY INFORMATION ______________________ ______________________ ______________________ MO HR WK PAID FOR DATE OF INJURY YES NO POLICY/MEMBER NUMBER
WILL YOU CONTINUE TO PAY WAGES INSTEAD OF WORKERS' COMP? YES
_________ / _________ / _________ DATE OF DEATH (If applicable)
PLACE OF ACCIDENT (Street, City, State, Zip) _________ / _________ / _________ Street: _____________________________________________________________
NAME, ADDRESS AND TELEPHONE OF PHYSICIAN OR HOSPITAL
AUTHORIZED BY EMPLOYER
YES
NO
1(a) Denied Case - DWC-12, Notice of Denial Attached 1(b) Indemnity Only Denied Case - DWC-12, Notice of Denial Attached
2. Medical Only which became Lost Time Case (Complete all required information in #3) Employee's 8TH Day of Disability _________ / _________ / _________
Entity's Knowledge of 8TH Day of Disability _________ /_________ / _________ 3. Lost Time Case - 1st day of disability _________ / _________ / _________ Date First Payment Mailed _________ / _________ / _________ Full Salary in lieu of comp? YES Full Salary End Date ________/ ________ / ________ Comp Rate ____________________________
AWW ____________________________
T.T.
T.T. - 80%
T.P.
I.B.
P.T.
DEATH
SETTLEMENT ONLY
Penalty Amount Paid in 1st Payment $___________
REMARKS:
Interest Amount Paid in 1st Payment $__________
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 (03/2009) Rule 69L-3.025, F.A.C.
DWC-1 Purpose and Use Statement The collection of the social security number on this form is specifically authorized by Section 440.185(2), Florida Statutes. The social security number will be used as a unique identifier in Division of Workers' Compensation database systems for individuals who have claimed benefits under Chapter 440, Florida Statutes. It will also be used to identify information and documents in those database systems regarding individuals who have claimed benefits under Chapter 440, Florida Statutes, for internal agency tracking purposes and for purposes of responding to both public records requests and subpoenas that require production of specified documents. The social security number may also be used for any other purpose specifically required or authorized by state or federal law.