First Report Of Injury Florida PDF Details

In the bustling world of Florida's workforce, where the unexpected can and often does happen, the First Report of Injury Florida form serves as an essential document for initiating the workers' compensation process. Managed by the Florida Department of Financial Services Division of Workers' Compensation, this form is a crucial first step for employees who have suffered an injury or illness due to their job. Designed to be filled out with clarity and precision, it requests detailed information including the employee's name, social security number, a comprehensive description of the accident along with its cause, and the nature and extent of the injury or illness. It also captures vital employer details, insurance information, and the crucial dates such as the accident's occurrence and when it was first reported. This form not only aids in the seamless processing of workers' compensation claims but also ensures that all parties involved have a clear record of the incident. Moreover, it plays a part in the broader context of workplace safety and insurance compliance, offering a structured approach to documenting and addressing workers' injuries. With its completion, the form sets the gears in motion for the necessary support and compensation mechanisms to be activated, providing a framework through which employees can report their injuries and initiate their recovery journey with confidence.

QuestionAnswer
Form NameFirst Report Of Injury Florida
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesfillable first report of injury form florida, florida work compo first report of injury, florida first report of injury, florida first report of injury fillable form

Form Preview Example

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

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

 

 

 

 

 

 

 

 

COMPANY NAME: ___________________________________________________

FEDERAL I.D. NUMBER (FEIN)

 

 

DATE FIRST REPORTED (Month/Day/Year)

 

 

 

 

 

 

 

 

 

 

 

D. B. A.: ____________________________________________________________

 

 

 

 

 

 

 

 

 

 

Street: _____________________________________________________________

NATURE OF BUSINESS

 

 

 

POLICY/MEMBER NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

City: _________________________ State: _______________ Zip: ______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TELEPHONE

Area Code

Number

 

DATE EMPLOYED

 

 

 

PAID FOR DATE OF INJURY

 

 

 

 

 

 

 

_________ / _________ / _________

 

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER'S LOCATION ADDRESS (If different)

 

LAST DATE EMPLOYEE WORKED

 

 

WILL YOU CONTINUE TO PAY WAGES INSTEAD OF

 

 

_________ / _________ / _________

WORKERS' COMP?

 

YES

 

 

 

 

 

 

 

Street: _____________________________________________________________

 

 

 

 

 

 

 

 

 

 

LAST DAY WAGES WILL BE PAID INSTEAD OF

 

 

 

 

 

RETURNED TO WORK

YES

 

NO

 

City: ________________________ State: _______________ Zip: ______________

 

WORKERS' COMP

 

 

 

 

IF YES, GIVE DATE

 

 

 

 

 

 

 

LOCATION # (If applicable) ____________________________________________

_________ / _________ / _________

_________ / _________ / _________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RATE OF PAY

 

 

 

 

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

 

DATE OF DEATH (If applicable)

 

 

 

 

HR

WK

 

 

 

 

 

 

 

 

 

 

_________ / _________ / _________

$ _________________ PER

 

 

 

Street: _____________________________________________________________

 

DAY

MO

 

 

 

 

 

 

 

 

City: _________________________ State: _______________ Zip: ______________

AGREE WITH DESCRIPTION OF ACCIDENT?

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 CODE #

EMPLOYEE'S CLASS CODE

EMPLOYER'S NAICS CODE

 

 

 

INSURER NAME

CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE

SERVICE CO/TPA CODE #

CLAIMS-HANDLING ENTITY FILE #

Form DFS-F2-DWC-1 (10/2016) 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.

How to Edit First Report Of Injury Florida Online for Free

The filling out the dwc 1 florida is actually quick. Our team ensured our software is not difficult to work with and helps complete any sort of form in no time. Take a look at a couple of steps you'll want to take:

Step 1: Press the "Get Form Now" button to start out.

Step 2: Now you will be within the form edit page. You can add, transform, highlight, check, cross, include or erase fields or text.

Type in the content requested by the application to prepare the document.

portion of empty spaces in report of injury form florida

Include the essential details in the Street, City State Zip, TELEPHONE, Area Code, Number, DATE EMPLOYED, PAID FOR DATE OF INJURY, YES, EMPLOYERS LOCATION ADDRESS If, Street, City State Zip, LAST DATE EMPLOYEE WORKED, WILL YOU CONTINUE TO PAY WAGES, YES, and RETURNED TO WORK IF YES GIVE DATE segment.

Finishing report of injury form florida part 2

In the b Indemnity Only Denied Case DWC, Employees TH Day of Disability, Entitys Knowledge of TH Day of, Lost Time Case st day of, YES Full Salary End Date, Date First Payment Mailed AWW, DEATH, SETTLEMENT ONLY, Penalty Amount Paid in st Payment, REMARKS, INSURER NAME, INSURER CODE, EMPLOYEES CLASS CODE, EMPLOYERS NAICS CODE, and CLAIMSHANDLING ENTITY NAME ADDRESS segment, point out the crucial information.

Filling out report of injury form florida part 3

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