Notice Of Denial
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1
2SENT TO DIVISION
DIVISION
NOTICE OF DENIAL
DATE
RECEIVED DATE
FLORIDA DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS’ COMPENSATION
200 East Gaines Street
Tallahassee, Florida 32399-4226
COMPLETE ALL APPLICABLE SECTIONS BEFORE FILING WITH THE DIVISION
PLEASE PRINT OR TYPE
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (First, Middle, Last)
DATE OF ACCIDENT:
(Month-Day-Year)
EMPLOYEE ADDRESS
EMPLOYER NAME
ATTACH ADDITIONAL PAGE(S) IF NECESSARY
DENIED BENEFITS (List below)
REASON FOR DENIAL OF BENEFITS (Provide detailed information to support reason(s) for denial)
DATE DENIAL RESCINDED: _____ / ____ / _______
Description of benefits reinstated or started:
CC: (Name and Address)
ADJUSTER NAME
ADJUSTER TELEPHONE
(
) __________ - ________________
_______
Ext.
INSURER CODE
DATE PREPARED
INSURER NAME
CLAIMS-HANDLING ENTITY NAME AND ADDRESS
SVC. CO/TPA CODE
CLAIMS-HANDLING ENTITY FILE
#
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.
Form DFS-F2-DWC-12 (03/2009) RULE 69L-3.025, F.A.C.
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