Employer Instructions For Completing The Les Form Dwc-1 (Page 4 of 4) in pdf

Employer Instructions For Completing The Les Form Dwc-1 Page 4

worked per day, the number of hours worked per week and the

number of days worked per week.

♦ “Name, Address and Telephone Of Physician Or Hospital” -

provide the name, complete mailing address (with zip code) and

telephone number (including area code) for the hospital or

physician that treated the injured employee. Also check the

appropriate box provided, if the physician/medical provider

was/was not authorized by you.

Wage Statement:

Within fourteen (14) days after you have knowledge of a lost time case, you

must report wage information to your insurance carrier on LES Form DWC-1A,

Wage Statement (be sure that you have the 11/’96 revised version). A lost time

case is a work injury or illness which has caused the employee to be out of work

for more than seven days or for which indemnity benefits have been paid.

You must also provide a copy of the completed LES Form DWC-1A and any

corrected form, to the employee or his/her estate if deceased. A copy of this form

is attached, including instructions for completing this form located on the reverse

side.

If you feel that you still need additional assistance in completing the

First Report of Injury /Illness, please call the Division of Workers’

Compensation, Bureau of Research and Education,

Customer Education and Information Services Section at (850) 921-6966.

This publication is being offered as an informational tool only, with the

understanding that this is not official language of the Florida Statutes. In no

event, will the State of Florida, Department of Labor and Employment Security,

Division of Workers’ Compensation be liable for any direct, indirect or

consequential damages resulting from the use of this printed material.

“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 commits a

felony of the third degree.”

Employer Instructions For Completing The Les Form Dwc-1 Page 4