Form DFS-F2-DWC-3 "Request for Wage Loss/Temporary Partial Benefits" - Florida

What Is Form DFS-F2-DWC-3?

This is a legal form that was released by the Florida Department of Financial Services - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2009;
  • The latest edition provided by the Florida Department of Financial Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DFS-F2-DWC-3 by clicking the link below or browse more documents and templates provided by the Florida Department of Financial Services.

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Download Form DFS-F2-DWC-3 "Request for Wage Loss/Temporary Partial Benefits" - Florida

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FLORIDA DEPARTMENT OF FINANCIAL SERVICES
RECEIVED BY CLAIMS-
SENT TO DIVISION
DIVISION RECEIVED
HANDLING ENTITY
DATE
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:
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
NO
IF YES, AMOUNT $ ____________________
ARE YOU RECEIVING UNEMPLOYMENT COMPENSATION?
YES
NO
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 document, 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 insurance fraud, punishable as provided in s. 817.234. Section 440.105(7),
F.S.
EMPLOYEE SIGNATURE __________________________________________________ DATE __________________________________________
CLAIMS-HANLDING 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
ADJ. WW
(Use applicable rate) __________ x __________
(Use applicable rate) __________ x __________
TOTAL GROSS EARNINGS
TOTAL GROSS EARNINGS
Discount Factor Applied?
Yes
No
Deemed earnings
Yes
No
Discount Factor Applied?
Yes
No
Deemed earnings
Yes
No
-
-
TOTAL WAGE LOSS
=
TOTAL WAGE LOSS
=
MULTIPLY BY APPLICABLE RATE
x
MULTIPLY BY APPLICABLE RATE
x
WAGE LOSS BENEFITS
=
WAGE LOSS BENEFITS
=
OFFSET (Identify benefits)
-
OFFSET (Identify benefits)
-
AMOUNT DUE/PAID
=
AMOUNT DUE/PAID
=
TOTAL AMOUNT PAID $ ____________________ Date _____/_____/_____
ADJUSTER NAME:
INSURER NAME:
DATE: _____/_____/_____
CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE:
ADJUSTER SIGNATURE:
Form DFS-F2-DWC-3 (03/2009) Rule 69L-3.025, F.A.C.
FLORIDA DEPARTMENT OF FINANCIAL SERVICES
RECEIVED BY CLAIMS-
SENT TO DIVISION
DIVISION RECEIVED
HANDLING ENTITY
DATE
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:
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
NO
IF YES, AMOUNT $ ____________________
ARE YOU RECEIVING UNEMPLOYMENT COMPENSATION?
YES
NO
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 document, 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 insurance fraud, punishable as provided in s. 817.234. Section 440.105(7),
F.S.
EMPLOYEE SIGNATURE __________________________________________________ DATE __________________________________________
CLAIMS-HANLDING 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
ADJ. WW
(Use applicable rate) __________ x __________
(Use applicable rate) __________ x __________
TOTAL GROSS EARNINGS
TOTAL GROSS EARNINGS
Discount Factor Applied?
Yes
No
Deemed earnings
Yes
No
Discount Factor Applied?
Yes
No
Deemed earnings
Yes
No
-
-
TOTAL WAGE LOSS
=
TOTAL WAGE LOSS
=
MULTIPLY BY APPLICABLE RATE
x
MULTIPLY BY APPLICABLE RATE
x
WAGE LOSS BENEFITS
=
WAGE LOSS BENEFITS
=
OFFSET (Identify benefits)
-
OFFSET (Identify benefits)
-
AMOUNT DUE/PAID
=
AMOUNT DUE/PAID
=
TOTAL AMOUNT PAID $ ____________________ Date _____/_____/_____
ADJUSTER NAME:
INSURER NAME:
DATE: _____/_____/_____
CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE:
ADJUSTER SIGNATURE:
Form DFS-F2-DWC-3 (03/2009) Rule 69L-3.025, F.A.C.
NAME
SOCIAL SECURITY NUMBER
WORK SEARCH REPORT
DURING THE TWO-WEEK PERIOD CLAIMED, I HAVE ATTEMPTED TO FIND EMPLOYMENT WITHIN MY PHYSICAL AND VOCATIONAL CAPABILITIES AT EACH BUSINESS, EMPLOYMENT
AGENCY AND JOB SERVICE OF FLORIDA LOCATION LISTED BELOW.
DATE
JOB
CONTACT
NAME, ADDRESS AND TELEPHONE
APPLICATION
RESULT OF
APPLIED FOR
PERSON
NUMBER OF COMPANY
FILED
CONTACT
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Form DFS-F2-DWC-3 (03/2009) Rule 69L-3.025, F.A.C.
DWC-3 Purpose and Use Statement
The collection of the social security number on this form is
imperative for the Division of Workers' Compensation's
performance of its duties and responsibilities as prescribed
by law. The social security number will be used as a unique
identifier in Division of Workers' Compensation database
systems for individuals who have claimed benefits under
Chapter 440, Florida Statutes. It will also be used to identify
information and documents in those database systems
regarding individuals who have claimed benefits under
Chapter 440, Florida Statutes, for internal agency tracking
purposes and for purposes of responding to both public
records requests and subpoenas that require production of
specified documents. The social security number may also be
used for any other purpose specifically required or
authorized by state or federal law.