Free DFS-F1-PW-2 - Florida

FLORIDA DEPARTMENT OF FINANCE SERVICES DIVISION OF WORKERS' COMPENSATION OFFICE OF SPECIAL DISABILITY TRUST FUND
200 East Gaines Street Tallahassee, Florida 32399-4223

SDTF RECEIVED DATE

PREFERRED WORKER REIMBURSEMENT REQUEST
PLEASE PRINT OR TYPE EMPLOYEE NAME

SDTF CLAIM NUMBER

DATE OF ACCIDENT

EMPLOYER NAME

EMPLOYER/FEIN NUMBER

DATE OF HIRE

HOURLY RATE OF PAY

CLASS CODE

SIC CODE

THE FOLLOWING MUST BE ATTACHED: 1) UCT-6 (OR OTHER ACCEPTABLE DOCUMENTATION OF PAYROLL AND JOB CLASSIFICATION FILED WITH THE DIVISION OF UNEMPLOYMENT COMPENSATION FOR ALL QUARTERS FOR WHICH REIMBURSEMENT IS REQUESTED). 2) 3) COPY OF THE PREMIUM CALCULATION SHEET. COPY OF THE PREMIUM AUDIT. TOTAL AMOUNT REIMBUREMENT REQUESTED

FROM:

PERIOD FOR WHICH REIMBURSEMENT IS REQUESTED TO:

TOTAL REIMBURSED PRIOR TO THIS REQUEST

NAME AND ADDRESS OF PAYEE:

COMMENTS:

PAYEE'S FEDERAL TAX I.D. NUMBER:

MAIL CHECK TO:

I HEREBY CERTIFY THAT ALL SUMS LISTED ON THIS FORM HAVE BEEN PAID.
PREPARER'S SIGNATURE: SIGNED BY: EMPLOYER NAME, ADDRESS & TELEPHONE

PREPARER'S TYPED NAME:

TITLE:

PREPARER'S TELEPHONE NUMBER:

DATE:

NOTE: This report MUST BE SIGNED by the employer or his duly authorized agent or carrier. SUPPORTING RECORDS are subject to audit by the Division of Workers' Compensation. The signed original and one copy MUST BE FILED WITH THE FUND by the employer requesting reimbursement.
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 IS GUILTY OF A FELONY OF THE THIRD DEGREE.

Form DFS-F1-PW-2 (Rev. 1/31/2008)