Les Form Dwc-3 - Request For Wage Loss/temporary Partial Benefits 1991

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DIVISION MICROFILM #
CARRIER AUDIT #
FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY
FOR CARRIER'S DATE STAMP
REC'D BY CARRIER
SENT TO DIVISION
DIVISION OF WORKERS' COMPENSATION
1-800-342-1741 or contact your local office for assistance
REQUEST FOR WAGE LOSS/TEMPORARY PARTIAL BENEFITS
COMPLETE ALL APPLICABLE SECTIONS BEFORE FILING WITH THE DIVISION
EMPLOYEE NAME & ADDRESS
EMPLOYER NAME & ADDRESS
SOCIAL SECURITY #
TELEPHONE:
TELEPHONE:
DATE OF ACCIDENT
EMPLOYEE: You must complete one of these forms every two weeks. Complete and sign this section and submit to the insurance carrier (adjuster) handling your claim.
ARE YOU RECEIVING SOCIAL SECURITY?
YES
NO
IF YES, AMOUNT $ ____________________
ARE YOU RECEIVING UNEMPLOYMENT COMPENSATION?
YES
NO
IF YES, AMOUNT $ ___________________
I CLAIM LOSS OF WAGES FOR TWO WEEKS AS FOLLOW
Week One _____/_____/_____
Week Two _____/_____/_____
I WAS EMPLOYED DURING THIS TWO WEEK PERIOD AS FOLLOWS:
(Attach check stub or other documentation.)
EMPLOYER NAME & ADDRESS ______________________________________________________________________________________________
EMPLOYER TELEPHONE (_____) ____________________________________________________________________________________________
Gross Wages:
Week One $ ____________________
Week Two $ ____________________
I WAS NOT EMPLOYED AND LOOKED FOR EMPLOYMENT AS DOCUMENTED ON THE BACK OF THIS FORM.
Upon making this claim and signing this document, I hereby authorize the release of Unemployment Compensation wage and benefit information and I hereby
authorize the release of Social Security information. I declare that the facts reported herein are true to the best of my knowledge and I understand that any
false or misleading statement I make could subject me to prosecution for fraud pursuant to section 440.37 Florida Statutes.
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.
EMPLOYEE SIGNATURE _____________________________________________________ DATE __________________________________________
CARRIER: Compute wage loss and complete other areas. Send employee copy with payment check and additional forms. Forward copy to employer (at time
of injury) and to Division.
WAGE LOSS: MMI Date _____/_____/_____ Rating __________%
TEMPORARY PARTIAL
CONTROVERTED - DWC-12 Attached
WEEKS ONE: _____/_____/_____ to _____/_____/_____
WEEK TWO: _____/_____/_____ to _____/_____/_____
AWW-BEFORE INJURY
ADJ. WW
AWW-BEFORE INJURY
ADJ. WW
(Use applicable rate) __________ x __________
(Use applicable rate) __________ x __________
TOTAL GROSS EARNINGS
TOTAL GROSS EARNINGS
Discount Factor Applied?
Yes
No
Deemed earnings
Yes
No
Discount Factor Applied?
Yes
No
Deemed earnings
Yes
No
-
-
TOTAL WAGE LOSS
=
TOTAL WAGE LOSS
=
MULTIPLY BY APPLICABLE RATE
x
MULTIPLY BY APPLICABLE RATE
x
WAGE LOSS BENEFITS
=
WAGE LOSS BENEFITS
=
OFFSET (Identify benefits)
-
OFFSET (Identify benefits)
-
AMOUNT DUE/PAID
=
AMOUNT DUE/PAID
=
TOTAL AMOUNT PAID $ ____________________ Date _____/_____/_____
ADJUSTER NAME:
CARRIER NAME, ADDRESS & TELEPHONE:
DATE: _____/_____/_____
ADJUSTER SIGNATURE:
LES Form DWC-3 (01/91)

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