Reimbursement Request Form - Special Disability Trust Fund - Florida Page 2
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6INSTRUCTIONS:
ATTACH APPROPRIATE DOCUMENTATION
1. TT - DWC-4
2. TP - DWC-3
3. WAGE LOSS - DWC-3's
4. PTD PAYSHEET
5. DEATH PAYSHEET
6. PI - DRAFT COPIES AND DWC-4's
NOTE: DWC-3's AND DWC-4's MUST BE FULLY COMPLETED WITH SIGNATURE, DATE PAID AND AMOUNT
PAID.
EMPLOYEE'S NAME
CLAIM NUMBER
DATE OF ACCIDENT
COMPENSATION
TEMPORARY
TEMPORARY
WAGE
PERMANENT
DEATH
PERMANENT
PERIOD
RATE
TOTAL
PARTIAL
LOSS
TOTAL
BENEFITS
IMPAIRMENT
TOTALS
Page _______________ of _______________
PAYMENT SCHEDULE A
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