Form DFS-F2-DWC-12 "Notice of Denial" - Florida

What Is Form DFS-F2-DWC-12?

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-12 by clicking the link below or browse more documents and templates provided by the Florida Department of Financial Services.

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SENT TO DIVISION
DIVISION
NOTICE OF DENIAL
DATE
RECEIVED DATE
FLORIDA DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS’ COMPENSATION
200 East Gaines Street
Tallahassee, Florida 32399-4226
COMPLETE ALL APPLICABLE SECTIONS BEFORE FILING WITH THE DIVISION
PLEASE PRINT OR TYPE
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (First, Middle, Last)
DATE OF ACCIDENT:
(Month-Day-Year)
EMPLOYEE ADDRESS
EMPLOYER NAME
ATTACH ADDITIONAL PAGE(S) IF NECESSARY
DENIED BENEFITS (List below)
REASON FOR DENIAL OF BENEFITS (Provide detailed information to support reason(s) for denial)
DATE DENIAL RESCINDED: _____ / ____ / _______
Description of benefits reinstated or started:
CC: (Name and Address)
ADJUSTER NAME
ADJUSTER TELEPHONE
(
) __________ - ________________
_______
Ext.
INSURER CODE
DATE PREPARED
INSURER NAME
CLAIMS-HANDLING ENTITY NAME AND ADDRESS
SVC. CO/TPA CODE
CLAIMS-HANDLING ENTITY FILE
#
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.
Form DFS-F2-DWC-12 (03/2009) RULE 69L-3.025, F.A.C.
SENT TO DIVISION
DIVISION
NOTICE OF DENIAL
DATE
RECEIVED DATE
FLORIDA DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS’ COMPENSATION
200 East Gaines Street
Tallahassee, Florida 32399-4226
COMPLETE ALL APPLICABLE SECTIONS BEFORE FILING WITH THE DIVISION
PLEASE PRINT OR TYPE
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (First, Middle, Last)
DATE OF ACCIDENT:
(Month-Day-Year)
EMPLOYEE ADDRESS
EMPLOYER NAME
ATTACH ADDITIONAL PAGE(S) IF NECESSARY
DENIED BENEFITS (List below)
REASON FOR DENIAL OF BENEFITS (Provide detailed information to support reason(s) for denial)
DATE DENIAL RESCINDED: _____ / ____ / _______
Description of benefits reinstated or started:
CC: (Name and Address)
ADJUSTER NAME
ADJUSTER TELEPHONE
(
) __________ - ________________
_______
Ext.
INSURER CODE
DATE PREPARED
INSURER NAME
CLAIMS-HANDLING ENTITY NAME AND ADDRESS
SVC. CO/TPA CODE
CLAIMS-HANDLING ENTITY FILE
#
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.
Form DFS-F2-DWC-12 (03/2009) RULE 69L-3.025, F.A.C.
DWC-12 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.
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