Proof Of Claim printable pdf download

Proof Of Claim

PROOF OF CLAIM

FLORIDA DEPARTMENT OF FINANCIAL SERVICES

DIVISION OF WORKERS' COMPENSATION

OFFICE OF SPECIAL DISABILITY TRUST FUND

200 E. Gaines Street

Tallahassee, Florida 32399-4223

SDTF Claim Number

Date of Accident for which

Date of this claim

Reimbursement is claimed

Name of Employee (address & phone number)

TT/Meds only

(D/A after 12/31/92)

[ ] Yes

[ ] No

Name of Employer (address & phone number)

Evidence of $10,000

Threshold attached

[ ] Yes

[ ] No

Name of Carrier (address & phone number)

Brief summary of Theory of Merger including pre-existing condition claimed and explanation of how it merged with instant accident to

cause payment of excess permanent compensation. Check whether merger is: [ ] wage loss

[ ] medical merger

[ ] TT/Meds only D/A 1/1/94 or later

Date of Maximum Medical Improvement:

Date of first payment of Permanent Benefits:

Permanent Impairment Rating:

Amount of Permanent Benefits Paid:

Please complete the attached Schedules and furnish appropriate documentation. Once a completed application

is received, your claim will be filed and placed in line for review. Incomplete claims will not be placed in line.

I hereby certify that I have made a good faith effort to enclose all pertinent materials requested.

SIGNATURE ___________________________________________________________________________________________

(For Employer, Carrier, Servicing Agent, Attorney).

Mailing Address _________________________________________________________________________________________

(Street No)

(City)

(State)

(Zip Code)

Form DFS-F1-SDF-1 (Rev. 3/09) Rule 69L-10.019, F.A.C.

Proof Of Claim