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NAME:

DATE/ACCIDENT:

TIME/ACC:

PLEASE USE THE SPACE BELOW TO EXPLAIN IN DETAIL YOUR PROBLEM:

FOR EXAMPLE: IF YOU FEEL YOU ARE OWED A CHECK, PUT THE DATE AND WHAT THE DOCTOR SAID

YOUR WORK STATUS WAS AT THAT TIME. (NO WORK, LIGHT DUTY, AND EARNING LESS OR LOOKING

FOR WORK, OR DOCTOR GAVE YOU PERMANENT RESTRICTIONS & YOU ARE LOOKING FOR WORK).

IF THE PROBLEM IS ABOUT AN UNPAID MEDICAL BILL, HOW MUCH THE BILL IS, WHAT DOCTOR OR

DRUGSTORE & THE DATES OF THE BILLS.

PROBLEM DEFINED:

______________________________________________________________________________________________________________________

NOTE: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY EMPLOYER OR EMPLOYEE,

INSURANCE CO. OR SELF-INSURED PROGRAM, FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE OR MISLEADING

INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.

It is the duty of all who participate in the workers’ compensation process to attempt to resolve disagreements in good faith.

Have you contacted the insurance carrier, or employer’s servicing company?

YES

Date Contacted:

Reason for no contact:

________________________________________________

Adjuster/Representative’s Name:

________________________________________________

Adjuster/Representative’s telephone number:

________________________________________________

SIGNATURE OF REQUESTOR: ____________________________________________________________ DATE:

______________________________

NAME, TITLE, ADDRESS, & TELEPHONE # OF REQUESTOR – IF NOT EMPLOYEE:

TELEPHONE: (______)

__________________________

______________________________________________________________________________________________________________________

WHEN YOU HAVE FULLY COMPLETED THIS FORM, PLEASE MAIL IT TO THIS ADDRESS,

OR IF YOU NEED ASSISTANCE, PLEASE CALL AT 1 (800) 342-1741

EMPLOYEE ASSISTANCE OFFICE

DIVISION OF WORKER’S COMPENSATION

P.O. BOX 8010

TALLAHASSEE, FLORIDA 32314-8010

EAO1-Rule_69L-26.002,F.A.C.

REV:4/21/08

Request For Assistance Form - Division Of Workers' Compensation State Of Florida - 2008 Page 2