Employee Earnings Report - Florida Department Of Financial Services
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1
2CLAIMS-HANDLING
SENT TO DIVISION
DIVISION RECEIVED
EMPLOYEE EARNINGS REPORT
ENTITY RECEIVED DATE
DATE
DATE
FLORIDA DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS’ COMPENSATION
CAUTION
FAILURE OR REFUSAL OF EMPLOYEE TO COMPLETE, SIGN, AND RETURN THIS
REPORT WITHIN 21 DAYS AFTER THE DATE OF RECEIPT OF THE REQUEST MAY
CAUSE PAYMENT OF BENEFITS TO STOP UNTIL SUCH TIME AS THE COMPLETED
FORM IS FURNISHED TO THE REQUESTING PARTY.
PLEASE PRINT OR TYPE
I. IDENTIFICATION OF PARTIES (To be completed by requesting party)
EMPLOYEE'S SOCIAL SECURITY NUMBER
EMPLOYEE'S NAME
DATE OF ACCIDENT:
(First, Middle, Last)
(Month-Day-Year)
EMPLOYEE'S ADDRESS
ACCIDENT EMPLOYER'S NAME & ADDRESS
CLAIMS-HANDLING ENTITY NAME & ADDRESS
II. NOTICE TO EMPLOYEE
THE WORKERS' COMPENSATION LAW REQUIRES ALL PERSONS RECEIVING OR CLAIMING BENEFITS FOR TEMPORARY DISABILITY AND/OR PERMANENT TOTAL
DISABILITY TO REPORT ALL EARNINGS OF ANY NATURE TO THE EMPLOYER, INSURANCE COMPANY AND/OR DIVISION OF WORKERS' COMPENSATION.
PLEASE
COMPLETE THIS REPORT AND RETURN IT TO THE REQUESTING PARTY WITHIN 21 DAYS AFTER THE DATE OF YOUR RECEIPT.
TIME PERIOD TO BE REPORTED
HAVE YOU RECEIVED INCOME FROM ANY SOURCE OTHER THAN WORKERS'
COMPENSATION?
FROM
TO
(IF YES, COMPLETE FORM, SIGN, DATE, & RETURN)
YES
(IF NO, SIGN, DATE AND RETURN)
NO
IF NECESSARY, ATTACH ADDITIONAL EARNINGS DOCUMENTATION
III. HAVE YOU RECEIVED EARNINGS FROM ANY PERSON, FIRM OR COMPANY
(IF YES, COMPLETE INFORMATION BELOW)
YES
DURING THE TIME PERIOD IN SECTION II?
NO
PERIOD WORKED
TOTAL
PERSON/FIRM/COMPANY NAME
ADDRESS
FROM
TO
GROSS
EARNINGS
IV. DURING THE TIME PERIOD IN SECTION II,
BRIEFLY DESCRIBE NATURE OF BUSINESS OR SERVICE
HAVE YOU BEEN SELF-EMPLOYED?
YES
NO
DATES SELF-EMPLOYED
DATES SELF-EMPLOYED
FROM
TO
WAGES, INCOME OR BENEFITS RECEIVED
FROM
TO
WAGES, INCOME OR BENEFITS RECEIVED
V. DURING THE TIME PERIOD IN SECTION II, HAVE YOU RECEIVED
YES
(IF YES, STATE AMOUNTS)
ANY SOCIAL SECURITY BENEFITS?
NO
TOTAL MONTHLY SOCIAL SECURITY INCOME
AMOUNT PAID FOR YOUR DISABILITY
AMOUNT PAID FOR YOUR DEPENDENTS
VI. DURING THE TIME PERIOD IN SECTION II, HAVE YOU RECEIVED WAGES, INCOME, OR BENEFITS
YES
(IF YES, STATE AMOUNTS)
FROM ANY OTHER SOURCE, i.e. Unemployment Compensation Benefits, Workers' Compensation
Benefits from another insurer, etc? Attach additional documentation if necessary.
NO
PERIOD BENEFITS RECEIVED
TOTAL AMOUNT
SOURCE OF WAGES, INCOME OR BENEFITS
FROM
TO
Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or
misleading information commits insurance fraud, punishable as provided in s. 817.234. Section 440.105(7), F.S.
I HAVE REVIEWED, UNDERSTAND, AND ACKNOWLEDGE THE ABOVE. THIS INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
EMPLOYEE'S SIGNATURE _____________________________________________________________________ DATE ____________________________________________________
VII. RETURN TO (To be completed by requesting party):
REQUESTING PARTY'S NAME
REQUESTING PARTY'S SIGNATURE
REQUESTING PARTY'S ADDRESS & TELEPHONE
TITLE
DATE:
(Month-Day-Year)
Form DFS-F2-DWC-19 (03/2009) Rule 69L-3.025, F.A.C.
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