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FLORIDA DEPARTMENT OF FINANCIAL SERVICES

RECEIVED BY CLAIMS-

SENT TO DIVISION

DIVISION RECEIVED

HANDLING ENTITY

DATE

DIVISION OF WORKERS' COMPENSATION

REQUEST FOR WAGE LOSS/TEMPORARY PARTIAL BENEFITS

1-800-342-1741 or contact your local office for assistance

COMPLETE ALL APPLICABLE SECTIONS BEFORE FILING WITH THE DIVISION

EMPLOYEE NAME (First, Middle, Last) & ADDRESS

EMPLOYER NAME & ADDRESS

SOCIAL SECURITY #

TELEPHONE:

DATE OF ACCIDENT:

(Month-Day-Year)

EMPLOYEE: You must complete one of these forms every two weeks. Complete and sign this section and submit to the claims-handling entity (adjuster) handling your claim.

ARE YOU RECEIVING SOCIAL SECURITY?

YES

IF YES, AMOUNT $ ____________________

ARE YOU RECEIVING UNEMPLOYMENT COMPENSATION?

YES

IF YES, AMOUNT $ ___________________

I CLAIM LOSS OF WAGES FOR TWO WEEKS AS FOLLOW

Week One _____/_____/_____

Week Two _____/_____/_____

I WAS EMPLOYED DURING THIS TWO WEEK PERIOD AS FOLLOWS:

(Attach check stub or other documentation.)

EMPLOYER NAME & ADDRESS

______________________________________________________________________________________________

EMPLOYER TELEPHONE (_____) ________________________________________________________________________________________

Gross Wages:

Week One $ ____________________

Week Two $ ____________________

I WAS NOT EMPLOYED AND LOOKED FOR EMPLOYMENT AS DOCUMENTED ON THE BACK OF THIS FORM.

Upon making this claim and signing this doc ument, I hereby authorize the release of Unemployment Compensation wage and benefit information and I

hereby authorize the release of Social Security

information. I declare that the facts reported herein are true to the best

of my knowledge and I

understand that any false or misleading statement I make could subject me to prosecution for fraud pursuant to Section 440.1051(3), Florida Statutes.

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 insuranc e fraud, punishable as provided in s. 817.234 . Section 440.105(7),

F.S.

EMPLOYEE SIGNATURE __________________________________________________ DATE __________________________________________

CLAIMS-HANDLING ENTITY: Compute wage loss and complete other areas. Send employee copy with payment check and additional forms. Forward

copy to employer (at time of injury) and to Division (upon request).

WAGE LOSS: MMI Date _____/_____/_____ Rating __________%

TEMPORARY PARTIAL

CONTROVERTED - DWC-12 Attached

WEEKS ONE: _____/_____/_____ to _____/_____/_____

WEEK TWO: _____/_____/_____ to _____/_____/_____

AWW-BEFORE INJURY

ADJ. WW

AWW-BEFORE INJURY