Form Dwc-22a - Alternate Carrier Reemployment Services Activity Report printable pdf download

Form Dwc-22a - Alternate Carrier Reemployment Services Activity Report

FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY

FOR CARRIER'S DATE STAMP

SENT TO DIVISION

DIVISION OF WORKERS' COMPENSATION

BUREAU OF REHABILITATION & MEDICAL SERVICES

2728 Centerview Drive, 100 Forrest Building

Tallahassee, Florida 32399-0664

ALTERNATE CARRIER REEMPLOYMENT SERVICES

ACTIVITY REPORT

REPORTING PERIOD

BEGINNING

ENDING

INSTRUCTIONS: This form is due by July 15 of

each calendar year for all form DWC-22's

completed on or after January 1 through June 30

of that calendar year and by January 15 for all

form DWC-22's completed on or after July 1

through December 31 of the previous calendar

year.

EMPLOYEE NAME

SOCIAL SECURITY #

DATE OF ACCIDENT

ACTIVITY CODE

DATE OF ACTIVITY

ACTIVITY CODES:

Carrier or SC/TPA name, address & telephone number

R1: Reemployment Case Review Status

R2: Annual Case Status Review

R3: Employer Commitment To Rehire

R4: Medical Care Coordination Provided

R5: Reemployment Assessment Provided

R6: Voluntary Reemployment Services Provided

R7: Case Referred to Division

Carrier Code #

SC/TPA Code #

Carrier FEIN

SC/TPA FEIN

LES Form DWC-22a (08/30/95)

Form Dwc-22a - Alternate Carrier Reemployment Services Activity Report