Free DFS-F2-DWC-3 - Florida

FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION REQUEST FOR WAGE LOSS/TEMPORARY PARTIAL BENEFITS
1-800-342-1741 or contact your local office for assistance
COMPLETE ALL APPLICABLE SECTIONS BEFORE FILING WITH THE DIVISION

RECEIVED BY CLAIMSHANDLING ENTITY

SENT TO DIVISION DATE

DIVISION RECEIVED DATE

EMPLOYEE NAME (First, Middle, Last) & ADDRESS

EMPLOYER NAME & ADDRESS

SOCIAL SECURITY #

TELEPHONE:

TELEPHONE:

DATE OF ACCIDENT:

(Month-Day-Year)

EMPLOYEE: You must complete one of these forms every two weeks. Complete and sign this section and submit to the claims-handling entity (adjuster) handling your claim.

ARE YOU RECEIVING SOCIAL SECURITY? YES NO IF YES, AMOUNT $ ____________________ ARE YOU RECEIVING UNEMPLOYMENT COMPENSATION? YES NO IF YES, AMOUNT $ ___________________ I CLAIM LOSS OF WAGES FOR TWO WEEKS AS FOLLOW Week One _____/_____/_____ Week Two _____/_____/_____ I WAS EMPLOYED DURING THIS TWO WEEK PERIOD AS FOLLOWS: EMPLOYER NAME & ADDRESS ______________________________________________________________________________________________ EMPLOYER TELEPHONE (_____) ________________________________________________________________________________________
Gross Wages: Week One $ ____________________ Week Two $ ____________________ (Attach check stub or other documentation.)

I WAS NOT EMPLOYED AND LOOKED FOR EMPLOYMENT AS DOCUMENTED ON THE BACK OF THIS FORM. Upon making this claim and signing this document, I hereby authorize the release of Unemployment Compensation wage and benefit information and I hereby authorize the release of Social Security information. I declare that the facts reported herein are true to the best of my knowledge and I understand that any false or misleading statement I make could subject me to prosecution for fraud pursuant to Section 440.1051(3), Florida Statutes. 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.

EMPLOYEE SIGNATURE __________________________________________________ DATE __________________________________________

CLAIMS-HANLDING ENTITY: Compute wage loss and complete other areas. Send employee copy with payment check and additional forms. Forward copy to employer (at time of injury) and to Division (upon request). WAGE LOSS: MMI Date _____/_____/_____ Rating __________% TEMPORARY PARTIAL CONTROVERTED - DWC-12 Attached WEEKS ONE: _____/_____/_____ to _____/_____/_____ AWW-BEFORE INJURY
(Use applicable rate) __________ x __________

WEEK TWO: _____/_____/_____ to _____/_____/_____ AWW-BEFORE INJURY
(Use applicable rate) __________ x __________

ADJ. WW

ADJ. WW

TOTAL GROSS EARNINGS
Discount Factor Applied? Yes No Deemed earnings Yes No

TOTAL GROSS EARNINGS = x = =
Discount Factor Applied? Yes No Deemed earnings Yes No

TOTAL WAGE LOSS MULTIPLY BY APPLICABLE RATE WAGE LOSS BENEFITS OFFSET (Identify benefits) AMOUNT DUE/PAID

TOTAL WAGE LOSS MULTIPLY BY APPLICABLE RATE WAGE LOSS BENEFITS OFFSET (Identify benefits) AMOUNT DUE/PAID

= x = =

TOTAL AMOUNT PAID $ ____________________ Date _____/_____/_____ ADJUSTER NAME: DATE: _____/_____/_____ CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE: ADJUSTER SIGNATURE: INSURER NAME:

Form DFS-F2-DWC-3 (03/2009) Rule 69L-3.025, F.A.C.

NAME

SOCIAL SECURITY NUMBER

WORK SEARCH REPORT
DURING THE TWO-WEEK PERIOD CLAIMED, I HAVE ATTEMPTED TO FIND EMPLOYMENT WITHIN MY PHYSICAL AND VOCATIONAL CAPABILITIES AT EACH BUSINESS, EMPLOYMENT AGENCY AND JOB SERVICE OF FLORIDA LOCATION LISTED BELOW. DATE JOB APPLIED FOR CONTACT PERSON NAME, ADDRESS AND TELEPHONE NUMBER OF COMPANY APPLICATION FILED YES NO YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES
Form DFS-F2-DWC-3 (03/2009) Rule 69L-3.025, F.A.C.

RESULT OF CONTACT

NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

DWC-3 Purpose and Use Statement The collection of the social security number on this form is imperative for the Division of Workers' Compensation's performance of its duties and responsibilities as prescribed by law. 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.