Form Dfs-F2-Dwc-1 - First Report Of Injury Or Illness Template Page 7
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9False and Fraudulent Claim Warning
Please read the following information carefully. This form must be signed and returned within 30 days of the date it was
received, stating that you have reviewed, understand and acknowledge the statement of benefits and/or payments shall
be suspended until such signature obtained.
Workers’ Compensation fraud includes but is not limited to the following:
Requesting and/or receiving temporary total, temporary partial, permanent total disability or
impairment benefits while working for gain as an employee of a business, independent contractor,
yourself or a business and not reporting that income to the insurance company.
Making a false or written statement and/or submitting false documents to your employer, your
physician and/or the insurance company or their representatives for the purpose of filing or supporting
a claim for workers’ compensation benefits.
Misrepresenting facts concerning an industrial accident, injury or illness to your employer, your
physician and/or the insurance company or their representatives.
Failing to report earnings when requested to do so by the insurance company.
Selling your personal information to third parties for use of misrepresenting facts to any medical
provider or insurance company.
Florida
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
insurance fraud punishable as provided in Florida Statute 817.234.
I have reviewed, understand and acknowledge the above. This information is true and correct to the best of my
knowledge.
Workers Name:
Please type or print
Claim #:_
Employee:
Employer: _________________________________________________________________________________________
Employees’ Address: ________________________________________________________________________________
Phone: ___________________________________________________________________________________________
Workers’ Signature:
Date: ____________________________________
Cannon Cochran Management Services, Inc.
2600 Lake Lucien Drive
Suite 225
Maitland, FL 32751
866‐291‐0194
407‐660‐5600
Fax: 217‐477‐6946
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Parent category: Business