First Report Of Injury Florida – Fill Out and Use

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.