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.
Question | Answer |
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Form Name | First Report Of Injury Florida |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | first report of injury form florida, florida first report of injury fillable form, report of injury form florida, florida work compo first report of injury |
FIRST REPORT OF INJURY OR ILLNESS
FLORIDA DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
For assistance call
Report all deaths within 24 hours
PLEASE PRINT OR TYPE
RECEIVED BY |
SENT TO DIVISION DATE |
DIVISION RECEIVED DATE |
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EMPLOYEE INFORMATION
NAME (First, Middle, Last) |
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Social Security Number |
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Date of Accident |
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Time of Accident |
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HOME ADDRESS |
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EMPLOYEE'S DESCRIPTION OF ACCIDENT (Include Cause of Injury) |
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Street/Apt #: _________________________________________________________ |
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City: _________________________ State: _______________ Zip: ______________ |
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TELEPHONE |
Area Code |
Number |
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OCCUPATION |
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INJURY/ILLNESS THAT OCCURRED |
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PART OF BODY AFFECTED |
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DATE OF BIRTH |
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SEX |
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_________ / _________ / _________ |
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EMPLOYER INFORMATION |
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FEDERAL I.D. NUMBER (FEIN) |
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DATE FIRST REPORTED (Month/Day/Year) |
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COMPANY NAME: ___________________________________________________ |
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D. B. A.: ____________________________________________________________ |
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NATURE OF BUSINESS |
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POLICY/MEMBER NUMBER |
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Street: _____________________________________________________________ |
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City: _________________________ State: _______________ Zip: ______________ |
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TELEPHONE |
Area Code |
Number |
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DATE EMPLOYED |
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PAID FOR DATE OF INJURY |
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_________ / _________ / _________ |
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YES |
NO |
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LAST DATE EMPLOYEE WORKED |
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WILL YOU CONTINUE TO PAY WAGES INSTEAD OF |
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EMPLOYER'S LOCATION ADDRESS (If different) |
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WORKERS' COMP? |
YES |
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_________ / _________ / _________ |
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Street: _____________________________________________________________ |
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RETURNED TO WORK |
YES |
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NO |
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LAST DAY WAGES WILL BE PAID INSTEAD OF |
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City: ________________________ State: _______________ Zip: ______________ |
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WORKERS' COMP |
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IF YES, GIVE DATE |
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LOCATION # (If applicable) ____________________________________________ |
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_________ / _________ / _________ |
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_________ / _________ / _________ |
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DATE OF DEATH (If applicable) |
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RATE OF PAY |
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HR |
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WK |
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PLACE OF ACCIDENT (Street, City, State, Zip) |
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_________ / _________ / _________ |
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$ _________________ PER |
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Street: _____________________________________________________________ |
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DAY |
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MO |
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AGREE WITH DESCRIPTION OF ACCIDENT? |
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City: _________________________ State: _______________ Zip: ______________ |
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Number of hours per day |
______________________ |
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COUNTY OF ACCIDENT ______________________________________________ |
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YES |
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NO |
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Number of hours per week |
______________________ |
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Number of days per week |
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Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or |
NAME, ADDRESS AND TELEPHONE |
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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 |
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F.S. |
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I have reviewed, understand and acknowledge the above statement. |
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__________________________________________________________________ |
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_______________________________________________ |
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EMPLOYEE SIGNATURE (If available to sign) |
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DATE |
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__________________________________________________________________ |
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_______________________________________________ |
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EMPLOYER SIGNATURE |
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DATE |
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AUTHORIZED BY EMPLOYER |
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NO |
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1(a) |
Denied Case - |
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2. Medical Only which became Lost Time Case (Complete all required information in #3) |
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1(b) |
Indemnity Only Denied Case - |
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Employee’s 8TH Day of Disability |
_________ / _________ / _________ |
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Entity’s Knowledge of 8TH Day of Disability _________ /_________ / _________ |
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3. Lost Time Case - 1st day of disability _________ / _________ / _________ |
Full Salary in lieu of comp? |
YES |
Full Salary End Date ________/ ________ / ________ |
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Date First Payment Mailed _________ / _________ / _________ |
AWW ____________________________ |
Comp Rate ____________________________ |
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T.T. |
T.T. - 80% |
T.P. |
I.B. |
P.T. |
DEATH |
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SETTLEMENT ONLY |
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Penalty Amount Paid in 1st Payment $___________ |
Interest Amount Paid in 1st Payment $__________ |
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REMARKS: |
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INSURER NAME |
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INSURER CODE # |
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EMPLOYEE'S CLASS CODE |
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EMPLOYER'S NAICS CODE |
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SERVICE CO/TPA CODE # |
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Form |
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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.