Form DFS-F2-DWC-13 "Claim Cost Report" - Florida

Form DFS-F2-DWC-13 or the "Claim Cost Report" is a form issued by the Florida Department of Financial Services.

The form was last revised in March 1, 2009 and is available for digital filing. Download an up-to-date Form DFS-F2-DWC-13 in PDF-format down below or look it up on the Florida Department of Financial Services Forms website.

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Download Form DFS-F2-DWC-13 "Claim Cost Report" - Florida

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DIVISION RECEIVED
CLAIM COST REPORT
SENT TO DIVISION DATE
DATE
FLORIDA DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
200 East Gaines Street
Tallahassee, FL 32399-4226
COMPLETE ALL APPLICABLE SECTIONS BEFORE FILING WITH THE DIVISION
PLEASE PRINT OR TYPE
SOCIAL SECURITY #
EMPLOYEE NAME:
DATE OF ACCIDENT:
(First, Middle, Last)
(Month-Day-Year)
TYPE OF REPORT
AVERAGE WEEKLY WAGE
COMPENSATION RATE
(Do not Round)
(Do not Round)
INITIAL REPORT SUMMARIZING FIRST SIX MONTHS
ANNUAL REPORT ON OPEN CASE
FINAL REPORT- CASE CLOSED; NO ACTIVITY IN PAST YEAR OR CASE SETTLED
YES
FULL SALARY END DATE _____ - _____ - _____
FULL SALARY IN LIEU OF COMPENSATION FOR ANY PERIOD OF TIME?
TYPE OF PAYMENT
WEEKS
DAYS
PAID TO DATE
TYPE OF PAYMENT
PAID TO DATE
COLUMN I
COLUMN II
(Do not round)
(Do not round)
TEMPORARY PARTIAL
MEDICAL
ALL DWC-9 & 11
TEMPORARY TOTAL
HOSPITAL
ALL DWC-90
TEMPORARY TOTAL – 80%
TRANSPORTATION
MEDICAL APPTS.
TEMPORARY TOTAL- TRAINING & EDUCATION
DRUGS/SUPPLIES
ALL DWC-10
IMPAIRMENT INCOME BENEFITS
HOME
ATTENDANT CARE
STATUTORY PERMANENT IMPAIRMENT
SKILLED
(D/A’s prior to 01/01/94)
NURSING CARE
WAGE LOSS
MISCELLANEOUS
(D/A”s prior to 01/01/94)
MEDICAL
SUPPLEMENTAL INCOME BENEFITS
REHABILITATION
ALL DWC-21
PERMANENT TOTAL
MEDICAL SETTLEMENT AMT.
Date accepted/adjud.: ______ - ______ - ______
Date Payment Mailed:
_____ - _____ - _____
PERMANENT TOTAL SUPPLEMENTAL
TOTAL
(PAID-TO-DATE COLUMNS I & II)
DEATH
FUNERAL
(Amounts entered in paid-to-date columns I & II should not
be reduced for recoveries except overpayment recoveries.)
COMPENSATION SETTLEMENT AMOUNT
THIRD PARTY RECOVERY AMOUNT: _________
Date Payment Mailed: _____ - _____ - _____
SPECIAL DISABILITY TRUST FUND
PENALTIES (Paid to Claimant)
RECOVERY AMOUNT:
_________
ALL OTHER RECOVERIES EXCEPT
OVERPAYMENTS:
_________
INTEREST (Paid to Claimant)
INSURER CODE #
DATE PREPARED:
INSURER NAME
(Month-Day-Year)
CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE
SERVICE 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-13 (03/2009) Rule 69L-3.025, F.A.C.
DIVISION RECEIVED
CLAIM COST REPORT
SENT TO DIVISION DATE
DATE
FLORIDA DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
200 East Gaines Street
Tallahassee, FL 32399-4226
COMPLETE ALL APPLICABLE SECTIONS BEFORE FILING WITH THE DIVISION
PLEASE PRINT OR TYPE
SOCIAL SECURITY #
EMPLOYEE NAME:
DATE OF ACCIDENT:
(First, Middle, Last)
(Month-Day-Year)
TYPE OF REPORT
AVERAGE WEEKLY WAGE
COMPENSATION RATE
(Do not Round)
(Do not Round)
INITIAL REPORT SUMMARIZING FIRST SIX MONTHS
ANNUAL REPORT ON OPEN CASE
FINAL REPORT- CASE CLOSED; NO ACTIVITY IN PAST YEAR OR CASE SETTLED
YES
FULL SALARY END DATE _____ - _____ - _____
FULL SALARY IN LIEU OF COMPENSATION FOR ANY PERIOD OF TIME?
TYPE OF PAYMENT
WEEKS
DAYS
PAID TO DATE
TYPE OF PAYMENT
PAID TO DATE
COLUMN I
COLUMN II
(Do not round)
(Do not round)
TEMPORARY PARTIAL
MEDICAL
ALL DWC-9 & 11
TEMPORARY TOTAL
HOSPITAL
ALL DWC-90
TEMPORARY TOTAL – 80%
TRANSPORTATION
MEDICAL APPTS.
TEMPORARY TOTAL- TRAINING & EDUCATION
DRUGS/SUPPLIES
ALL DWC-10
IMPAIRMENT INCOME BENEFITS
HOME
ATTENDANT CARE
STATUTORY PERMANENT IMPAIRMENT
SKILLED
(D/A’s prior to 01/01/94)
NURSING CARE
WAGE LOSS
MISCELLANEOUS
(D/A”s prior to 01/01/94)
MEDICAL
SUPPLEMENTAL INCOME BENEFITS
REHABILITATION
ALL DWC-21
PERMANENT TOTAL
MEDICAL SETTLEMENT AMT.
Date accepted/adjud.: ______ - ______ - ______
Date Payment Mailed:
_____ - _____ - _____
PERMANENT TOTAL SUPPLEMENTAL
TOTAL
(PAID-TO-DATE COLUMNS I & II)
DEATH
FUNERAL
(Amounts entered in paid-to-date columns I & II should not
be reduced for recoveries except overpayment recoveries.)
COMPENSATION SETTLEMENT AMOUNT
THIRD PARTY RECOVERY AMOUNT: _________
Date Payment Mailed: _____ - _____ - _____
SPECIAL DISABILITY TRUST FUND
PENALTIES (Paid to Claimant)
RECOVERY AMOUNT:
_________
ALL OTHER RECOVERIES EXCEPT
OVERPAYMENTS:
_________
INTEREST (Paid to Claimant)
INSURER CODE #
DATE PREPARED:
INSURER NAME
(Month-Day-Year)
CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE
SERVICE 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-13 (03/2009) Rule 69L-3.025, F.A.C.
DWC-13 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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