Florida First Report Of Injury Form Fillable 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?No
Fillable fields0
Avg. time to fill out30 sec
Other namesfirst report of injury form florida, florida first report of injury fillable form, report of injury form florida, florida work compo 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

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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