Les Form Dwc-12 - Notice Of Denial

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FOR CARRIER’S DATE STAMP
NOTICE TO:
SENT TO DIVISION
FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY
DIVISION OF WORKERS’ COMPENSATION
2728 Centerview Drive, 202 Forrest Building
Tallahassee, Florida 32399-0685
NOTICE OF DENIAL
COMPLETE ALL APPLICABLE SECTIONS BEFORE FILING WITH THE DIVISION
PLEASE PRINT OR TYPE
EMPLOYEE NAME
SOCIAL SECURITY NUMBER
DATE OF ACCIDENT
EMPLOYEE ADDRESS
EMPLOYER NAME
NOTICE TO EMPLOYEE, EMPLOYER, AND PROVIDER
If you do not agree with the carrier’s action, or you do not understand why you received this information, contact your adjuster. If you need further assistance,
please contact the Employee Assistance and Ombudsman Office at its toll free number 1-800-342-1741, or visit at your convenience, one of our specialists at
a local office for assistance.
ATTACH ADDITIONAL PAGE(S) IF NECESSARY
DENIED BENEFITS (List below)
LOST TIME CASE
MEDICAL ONLY CASE
REASON FOR DENIAL OF BENEFITS (Provide detailed information to support reason(s) for denial)
DATE DENIAL
If a Denial of Lost Time Benefits is being rescinded, a DWC-4 form
must be attached reflecting the Initial Indemnity Start Date and Disability
RESCINDED: ______ / _____ / __________
Type and the Average Weekly Wage and Compensation Rate.
CC: (Name and Address)
ADJUSTER NAME
ADJUSTER TELEPHONE
(
) __________ - ________________ Ext. _______
CARRIER CODE
DATE PREPARED
CARRIER NAME AND ADDRESS
SVC. CO/TPA CODE
CARRIER FILE #
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.
LES Form DWC-12 (11/94)

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