Les Form Dwc-35 - Permanent Total Supplemental Worksheet
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1FLORIDA DEPARTMENT OF LABOR & EMPLOYMENT SECURITY
FOR CARRIER'S DATE STAMP
SENT TO DIVISION
DIVISION OF WORKERS' COMPENSATION
BUREAU OF MONITORING AND AUDIT
2562 Executive Center Drive, 100 Montgomery Building
Tallahassee, Florida 32399-0684
PERMANENT TOTAL SUPPLEMENTAL WORKSHEET
PLEASE PRINT OR TYPE
EMPLOYEE NAME, ADDRESS & TELEPHONE:
SOCIAL SECURITY #:
DATE OF ACCIDENT:
GUARDIAN, If applicable
DATE OF BIRTH:
PT ACCEPTANCE/ADJUDICATION DATE
___________________________________
Carrier Pay
Division Pay
COMPUTATION OF SUPPLEMENTAL WEEKLY COMPENSATION
AWW:
$
80% AWW:
$
STEP 1:
A.
$
Enter employee's compensation rate in accordance with the Law in effect on the date of accident
B. x
$
Amount of 5% supplemental authorized
C. =
$
Basic Weekly Increase
D. x
$
Number of CALENDAR years since the date of accident
* Subtract year of accident from year of PT Acceptance/Adjudication
E. =
$
Total weekly supplement - Enter below in (A1)
STEP 2:
A.
$
(Enter the figure from STEP 1A)
B. +
$
(Enter the figure from STEP 1E)
C. =
$
(TOTAL cannot exceed maximum for appropriate year)
THE MAXIMUM WEEKLY COMPENSATION RATE:
1. $_______________
per week, beginning
__________________
4. $_______________
per week, beginning
__________________
2. $_______________
per week, beginning
__________________
5. $_______________
per week, beginning
__________________
3. $_______________
per week, beginning
__________________
6. $_______________
per week, beginning
__________________
STEP 3: Weekly supplement divided by 7 x total number of days in year. Combine yearly amounts to get total initial payment due to claimant.
(A1)
Beginning Date
Ending Date
(B1)
(C1)
Comments
Weekly Supplement Rate
(MM/DD/YY)
(MM/DD/YY)
Total Number
Total Amount
(if any)
of Days
(A1 divided by 7 x B1 = C1)
TOTAL INITIAL PAYMENT
$
First Regular Payment Amount
$
Payment Date
(Weekly Amount x 4 = Division Pay)
(Weekly Amount x 2 = Carrier Pay)
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 IS GUILTY OF A FELONY OF THE THIRD DEGREE.
CARRIER CODE #
ADJUSTER NAME
CARRIER NAME, ADDRESS & TELEPHONE #
SERVICE CO./TPA CODE #
DATE PREPARED
LES Form DWC-35
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