First Report Dfs F2 Dwc 1 Form PDF Details

When an employee suffers an injury or illness due to their job in Florida, the First Report of Injury or Illness form, known as DFS-F2-DWC-1, plays a crucial role in initiating the workers' compensation process. Managed by the Florida Department of Financial Services Division of Workers' Compensation, this document is required to be filled out and submitted by employers to report any workplace injuries or illnesses. Essential information captured on this form includes detailed employee information, a description of the accident and injury or illness incurred, employer details, and specifics about the injury or illness such as the date of accident, part of the body affected, and whether it resulted in any death. Employers are also required to report if they will continue to pay wages instead of workers' compensation. A noteworthy aspect of this form is its emphasis on accuracy and truthfulness, highlighting that submitting false or misleading information may constitute insurance fraud. Additionally, the form outlines the use of the employee's social security number as a unique identifier within the Division's database systems, underscoring the importance of this information for tracking benefits and responding to official inquiries. The DFS-F2-DWC-1 form is a foundational step in ensuring employees receive the necessary support and compensation following workplace injuries or illnesses, while also promoting transparency and integrity within the process.

QuestionAnswer
Form NameFirst Report Dfs F2 Dwc 1 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform dfs f2 dwc 1, first report of injury form fillable, florida first report of injury, first report of injury form

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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

PLEASE PRINT OR TYPE

RECEIVED BY

SENT TO DIVISION DATE

DIVISION RECEIVED DATE

CLAIMS-HANDLING ENTITY

 

 

 

 

 

EMPLOYEE INFORMATION

NAME (First, Middle, Last)

 

 

 

 

 

Social Security Number

 

 

 

Date of Accident (Month-Day-Year)

 

Time of Accident

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AM

PM

HOME ADDRESS

 

 

 

 

 

EMPLOYEE'S DESCRIPTION OF ACCIDENT (Include Cause of Injury)

 

 

 

 

Street/Apt #: _________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City: _________________________ State: _______________ Zip: ______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TELEPHONE

Area Code

Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

POLICY/MEMBER NUMBER

 

 

 

Street: _____________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City: _________________________ State: _______________ Zip: ______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TELEPHONE

Area Code

Number

 

 

DATE EMPLOYED

 

 

 

 

 

PAID FOR DATE OF INJURY

 

 

 

 

 

 

 

 

 

 

 

_________ / _________ / _________

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LAST DATE EMPLOYEE WORKED

 

 

 

 

WILL YOU CONTINUE TO PAY WAGES INSTEAD OF

 

EMPLOYER'S LOCATION ADDRESS (If different)

 

 

 

 

 

 

 

 

 

 

WORKERS' COMP?

YES

 

 

 

 

 

 

 

 

 

 

 

_________ / _________ / _________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street: _____________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RETURNED TO WORK

YES

 

NO

 

LAST DAY WAGES WILL BE PAID INSTEAD OF

 

City: ________________________ State: _______________ Zip: ______________

 

 

 

WORKERS' COMP

 

 

 

 

 

IF YES, GIVE DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCATION # (If applicable) ____________________________________________

 

 

_________ / _________ / _________

 

_________ / _________ / _________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF DEATH (If applicable)

 

 

 

 

RATE OF PAY

 

HR

 

WK

PLACE OF ACCIDENT (Street, City, State, Zip)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_________ / _________ / _________

 

$ _________________ PER

 

 

 

Street: _____________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

DAY

 

MO

 

 

 

 

 

 

 

AGREE WITH DESCRIPTION OF ACCIDENT?

 

 

 

 

 

 

 

City: _________________________ State: _______________ Zip: ______________

 

 

 

 

 

 

 

 

Number of hours per day

______________________

COUNTY OF ACCIDENT ______________________________________________

 

 

YES

 

NO

 

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

NAME, ADDRESS AND TELEPHONE

 

 

statement of claim containing any false or misleading information commits insurance fraud, punishable as provided in s. 817.234. Section 440.105(7),

OF PHYSICIAN OR HOSPITAL

 

 

 

F.S.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I have reviewed, understand and acknowledge the above statement.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

__________________________________________________________________

 

_______________________________________________

 

 

 

 

 

 

 

EMPLOYEE SIGNATURE (If available to sign)

 

 

 

 

DATE

 

 

 

 

 

 

 

 

 

 

__________________________________________________________________

 

_______________________________________________

 

 

 

 

 

 

 

 

EMPLOYER SIGNATURE

 

 

 

 

 

DATE

 

 

 

 

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 8TH Day of Disability

_________ / _________ / _________

 

 

 

 

 

 

 

 

 

Entity’s Knowledge of 8TH 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 1st Payment $___________

Interest Amount Paid in 1st 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 (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.

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Tips on how to fill out report of injury form stage 1

2. Once your current task is complete, take the next step – fill out all of these fields - EMPLOYERS LOCATION ADDRESS If, RETURNED TO WORK IF YES GIVE DATE, YES, DATE OF DEATH If applicable, AGREE WITH DESCRIPTION OF ACCIDENT, YES, LAST DAY WAGES WILL BE PAID, RATE OF PAY PER, Number of hours per day, HR DAY, Number of hours per week, Number of days per week, Any person who knowingly and with, NAME ADDRESS AND TELEPHONE OF, and YES with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Stage number 2 of submitting report of injury form

Always be extremely careful when completing YES and DATE OF DEATH If applicable, since this is where most users make a few mistakes.

3. Within this stage, look at Penalty Amount Paid in st Payment, EMPLOYEES CLASS CODE, EMPLOYERS NAICS CODE, INSURER NAME CLAIMSHANDLING ENTITY, SERVICE COTPA CODE, CLAIMSHANDLING ENTITY FILE, and Form DFSFDWC Rule L FAC. Each of these have to be taken care of with highest precision.

How to complete report of injury form step 3

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