First Report Of Injury Florida PDF Details

In the State of Florida, there is a form that you are required to fill out and submit to your employer in the event that you sustain an injury on the job. This form is known as the First Report of Injury Florida Form, and it must be submitted to your employer within seven days of sustaining the injury. The purpose of this form is to provide your employer with information about the injury, including when and how it occurred, as well as any medical treatment that has been or will be received. If you have any questions about the First Report of Injury Florida Form or need assistance filing it, please contact our team.

Here is the details regarding the form you were seeking to fill out. It will tell you the amount of time you will need to complete first report of injury florida, what fields you need to fill in and a few other specific details.

QuestionAnswer
Form NameFirst Report Of Injury Florida
Form Length2 pages
Fillable?Yes
Fillable fields108
Avg. time to fill out22 min 10 sec
Other namesfillable first report of injury form florida, florida first report of injury form 2018, florida workers compensation accident report, florida first report of injury

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 fillable first report of injury form 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 first report of injury form

Include the essential details in the YES, EMPLOYERS, LOCATION, ADDRESS, If, different Street, City, State, Zip LOCATION, If, applicable LAST, DATE, EMPLOYEE, WORKED RETURNED, TO, WORK, IF, YES, GIVE, DATE YES, YES, DATE, OF, DEATH, If, applicable RATE, OF, PAY PER, DAY, PLACEOFACCIDENTStreetCity, State, Zip and Street segment.

Finishing first report of injury form part 2

In the Date, First, Payment, Mailed, A, WW, Comp, Rate DEATH, SETTLEMENT, ONLY REMARKS, INSURER, NAME INSURER, CODE EMPLOYEES, CLASS, CODE EMPLOYERS, NAIC, S, CODE SERVICE, COT, PACO, DE CLAIMS, HANDLING, ENTITY, FILE and Form, D, FSF, DW, C, Rule, L, FAC segment, point out the crucial information.

Filling out first report of injury form part 3

Step 3: Hit the Done button to save the document. At this point it is ready for upload to your gadget.

Step 4: Try to create as many duplicates of your form as you can to keep away from potential problems.

Watch First Report Of Injury Florida Video Instruction

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .