Form Dfs-F2-Dwc-1 - First Report Of Injury Or Illness Template

Download a blank fillable Form Dfs-F2-Dwc-1 - First Report Of Injury Or Illness Template in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Dfs-F2-Dwc-1 - First Report Of Injury Or Illness Template with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

RECEIVED BY
CLAIMS-HANDLING ENTITY
SENT TO DIVISION DATE
DIVISION RECEIVED DATE
FIRST REPORT OF INJURY OR ILLNESS
FLORIDA DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
For assistance call 1-800-342-1741
or contact your local EAO Office
Report all deaths within 24 hours 1-800-219-8953 or (850) 922-8953
PLEASE PRINT OR TYPE
EMPLOYEE INFORMATION
NAME (First, Middle, Last)
Social Security Number
Date of Accident (Month-Day-Year)
Time of Accident
□ AM
□ PM
HOME ADDRESS
EMPLOYEE'S DESCRIPTION OF ACCIDENT (Include Cause of Injury)
Street/Apt #: _________________________________________________________
City: _________________________ State: _______________ Zip: _____________
TELEPHONE
Area Code
Number
OCCUPATION
INJURY/ILLNESS THAT OCCURRED
PART OF BODY AFFECTED
DATE OF BIRTH
SEX
□ M □ F
_________ / _________ / _________
EMPLOYER INFORMATION
COMPANY
FEDERAL I.D. NUMBER (FEIN)
DATE FIRST REPORTED (Month/Day/Year)
NAME: Nova Southeastern University__________________________
D. B. A.: _________Same______________________________________________
59-1083502
Street: _3301 College Avenue__________________________________________
NATURE OF BUSINESS
POLICY/MEMBER NUMBER
City: _Ft Lauderdale_________ State: Florida___________ Zip: _33314________
Education
2499309
TELEPHONE
Area Code
Number
DATE EMPLOYED
PAID FOR DATE OF INJURY
□ YES
□ NO
_________ / _________ / _________
EMPLOYER'S LOCATION ADDRESS (If different)
LAST DATE EMPLOYEE WORKED
WILL YOU CONTINUE TO PAY WAGES INSTEAD OF
WORKERS' COMP? □ YES
Street: _____________________________________________________________
_________ / _________ / _________
LAST DAY WAGES WILL BE PAID INSTEAD OF
WORKERS' COMP
RETURNED TO WORK □YES
□ NO
City: ________________________ State: _______________ Zip: ______________
IF YES, GIVE DATE
_________ / _________ / _________
LOCATION # (If applicable) ____________________________________________
_________ / _________ / _________
RATE OF PAY
□ HR
□ WK
PLACE OF ACCIDENT (Street, City, State, Zip)
DATE OF DEATH (If applicable)
$ _________________ PER
□ DAY
□ MO
Street: _____________________________________________________________
_________ / _________ / _________
Number of hours per day
___________________
City: _________________________ State: _______________ Zip: ______________
Number of hours per week
___________________
AGREE WITH DESCRIPTION OF ACCIDENT?
Number of days per week
___________________
□ YES
□ NO
COUNTY OF ACCIDENT ______________________________________________
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
NAME, ADDRESS AND TELEPHONE
of claim containing any false or misleading information commits insurance fraud, punishable as provided in s. 817.234. Section 440.105(7), F.S. I have reviewed,
OF PHYSICIAN OR HOSPITAL
understand and acknowledge the above statement.
_____________________________________________________________________
_______________________________________
EMPLOYEE SIGNATURE (If available to sign)
DATE
__________________________________________________________________ __
________________________________________
AUTHORIZED BY EMPLOYER
□ YES
□ NO
EMPLOYER SIGNATURE
DATE
CLAIMS-HANDLING ENTITY INFORMATION
□1 (a) Denied Case - DWC-12, Notice of Denial Attached
□ 2. Medical Only which became Lost Time Case (Complete all required information in #3)
□1(b) Indemnity Only Denied Case - DWC-12, Notice of Denial Attached
Employee’s 8TH Day of Disability _________ / _________ / _________
Entity’s Knowledge of 8TH Day of Disability _________ /_________ / _________
□ 3. Lost Time Case - 1st day of disability _________ / _________ / _________
Full Salary in lieu of comp? YES
Full Salary End Date ________/ ________ / ________
Date First Payment Mailed _________ / _________ / _________
AWW ____________________________
Comp Rate ____________________________
□ T.T.
□ T.T. - 80%
□ T.P.
□I.B.
□ P.T.
□ DEATH
□ SETTLEMENT ONLY
Penalty Amount Paid in 1st Payment $___________
Interest Amount Paid in 1st Payment $__________
REMARKS:
INSURER NAME
CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE
INSURER CODE #
EMPLOYEE'S CLASS CODE
EMPLOYER'S NAICS CODE
Cannon Cochran Management Services, Inc.
SERVICE CO/TPA CODE #
CLAIMS-HANDLING ENTITY FILE #
‐660‐
‐477‐
866‐291‐
Form DFS-F2-DWC-1 (12/2009)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 9