CARRIER RECEIVED DATE
SENT TO DIVISION DATE
STATEMENT OF QUARTERLY EARNINGS
FOR SUPPLEMENTAL INCOME BENEFITS
FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY
DIVISION OF WORKERS' COMPENSATION
1-800-342-1741 or contact your local office for assistance
PLEASE PRINT OR TYPE
A
EMPLOYEE NAME
SOCIAL SECURITY NUMBER
DATE OF ACCIDENT
ACCIDENT EMPLOYER NAME
FILING PERIOD:
___________________________________ THROUGH ___________________________________
BEGINNING DATE
ENDING DATE
B
NOTICE TO EMPLOYEE: Report all wages earned during the filing period in the area provided below.
PLEASE CHECK APPROPRIATE BOXES:
*** See instructions on the back side of this form ***
I RETURNED TO WORK BUT MY REDUCED WAGES WERE A DIRECT RESULT OF MY IMPAIRMENT FROM THIS INJURY.
DURING ANY WEEKS I WAS NOT EMPLOYED, I HAVE IN GOOD FAITH ATTEMPTED TO OBTAIN EMPLOYMENT WHICH I AM ABLE TO DO.
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.
I HAVE REVIEWED, UNDERSTAND, AND ACKNOWLEDGE THAT THE INFORMATION PROVIDED ON THIS FORM AND ANY ATTACHMENTS IS TRUE AND CORRECT.
EMPLOYEE SIGNATURE: _____________________________________________________________________________________________ DATE: _________________________________
GRATUITIES
(CARRIER
FRINGE BENEFITS (employee rec'd)
C
CURRENT RATE OF PAY: $_______________PER
HR
WK
DAY
MO
AS REPORTED
USE
HOURS PER DAY ____________
HOURS PER WEEK__________
DAYS PER WEEK __________
TO THE
ONLY)
EMPLOYER COST ONLY
WEEK
# OF DAYS
# OF HOURS
EMPLOYER IN
WEEK
WORKED
WORKED
GROSS
WRITING AS
DEEMED
HEALTH
RENT/
NO.
FROM
TO
THAT WEEK
THAT WEEK
PAY
TAXABLE
WAGES
INSURANCE
HOUSING
1
2
3
4
5
6
7
8
9
10
11
12
13
AREA BELOW FOR CARRIER USE ONLY
1
2
3
4
5
TOTALS:
MONTHLY SUPP. BENEFITS CALCULATION
BENEFIT ADJUSTMENT DUE TO OVERPAYMENT
$
D
Pre-injury AWW x 4.3 x 0.80 =
Adjusted Monthly Wage
$
Amount Paid for ____/____/____ thru ____/____/____
TOTAL OF
Minus (Current AWW x 4.3) =
Current Monthly Wage
1+2+3+4+5
$
Paid on
______/______/______
$
Equals Total Monthly
Wage Loss
$
Amount Due for ____/____/____ thru ____/____/____
$
DIVIDE BY #
Multiplied by 0.80 =
Monthly S.I.B. Payable
Total Amount of Overpayment Credit
OF WEEKS IN
$
$
EQUALS
FILING PERIOD
Payment Period
Amount of Overpayment Credit applied per month
CURRENT
$
________/________/________ thru ________/________/________
(Not to EXCEED 20% of Monthly Payment)
$
AVERAGE
Subject to Maximum Payable
Monthly Adjusted Amount due for
WEEKLY
at Comp Rate __________ x 4.3
$
______/______/______ thru ______/______/______
$
WAGE
Payment Amount for Initial
Remaining Overpayment Credit
Month
$
$
ADJUSTER NAME:
Payment for filing period denied. See attached Notice of Denial.
CARRIER CODE #
DATE PREPARED
RETURN THIS FORM TO:
CARRIER NAME, ADDRESS AND TELEPHONE
SERVICE CO/TPA CODE #
CARRIER FILE #
LES Form DWC-40 (11/94)