Free DFS-F2-DWC-13 - Florida


File Size: 37.7 kB
Pages: 2
Date: March 27, 2009
File Format: PDF
State: Florida
Category: Workers Compensation
Author: Fred Becknell
Word Count: 472 Words, 3,269 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.fldfs.com/wc/pdf/DFS-F2-DWC-13.pdf

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CLAIM COST REPORT
FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION
200 East Gaines Street Tallahassee, FL 32399-4226
COMPLETE ALL APPLICABLE SECTIONS BEFORE FILING WITH THE DIVISION PLEASE PRINT OR TYPE
SOCIAL SECURITY # EMPLOYEE NAME:
(First, Middle, Last)

SENT TO DIVISION DATE

DIVISION RECEIVED DATE

DATE OF ACCIDENT:

(Month-Day-Year)

TYPE OF REPORT
INITIAL REPORT SUMMARIZING FIRST SIX MONTHS ANNUAL REPORT ON OPEN CASE FINAL REPORT- CASE CLOSED; NO ACTIVITY IN PAST YEAR OR CASE SETTLED

AVERAGE WEEKLY WAGE (Do not Round)

COMPENSATION RATE (Do not Round)

FULL SALARY IN LIEU OF COMPENSATION FOR ANY PERIOD OF TIME?
TYPE OF PAYMENT TEMPORARY PARTIAL WEEKS DAYS

YES
PAID TO DATE COLUMN I
(Do not round)

FULL SALARY END DATE _____ - _____ - _____
TYPE OF PAYMENT MEDICAL ALL DWC-9 & 11 HOSPITAL ALL DWC-90 TRANSPORTATION MEDICAL APPTS. DRUGS/SUPPLIES ALL DWC-10 HOME ATTENDANT CARE SKILLED NURSING CARE MISCELLANEOUS MEDICAL REHABILITATION ALL DWC-21 MEDICAL SETTLEMENT AMT. Date Payment Mailed: _____ - _____ - _____ PAID TO DATE COLUMN II
(Do not round)

TEMPORARY TOTAL

TEMPORARY TOTAL 80%

TEMPORARY TOTAL- TRAINING & EDUCATION

IMPAIRMENT INCOME BENEFITS

STATUTORY PERMANENT IMPAIRMENT (D/A's prior to 01/01/94) WAGE LOSS (D/A"s prior to 01/01/94) SUPPLEMENTAL INCOME BENEFITS

PERMANENT TOTAL Date accepted/adjud.: ______ - ______ - ______ PERMANENT TOTAL SUPPLEMENTAL

TOTAL
(PAID-TO-DATE COLUMNS I & II)

DEATH

FUNERAL

(Amounts entered in paid-to-date columns I & II should not be reduced for recoveries except overpayment recoveries.) THIRD PARTY RECOVERY AMOUNT: _________ SPECIAL DISABILITY TRUST FUND RECOVERY AMOUNT: ALL OTHER RECOVERIES EXCEPT OVERPAYMENTS: _________ _________

COMPENSATION SETTLEMENT AMOUNT Date Payment Mailed: _____ - _____ - _____ PENALTIES (Paid to Claimant)

INTEREST (Paid to Claimant)

INSURER CODE #

DATE PREPARED: (Month-Day-Year)

INSURER NAME

CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE SERVICE CO./TPA CODE # CLAIMS-HANDLING ENTITY FILE #

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.
Form DFS-F2-DWC-13 (03/2009) Rule 69L-3.025, F.A.C.

DWC-13 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.