Form DFS-F2-DWC-14 "Request for Social Security Disability Benefit Information" - Florida

What Is Form DFS-F2-DWC-14?

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-14 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-14 "Request for Social Security Disability Benefit Information" - Florida

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RECEIVED BY CLAIMS-
REQUEST FOR SOCIAL SECURITY DISABILITY BENEFIT INFORMATION
HANDLING ENTITY
FLORIDA DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS’ COMPENSATION
(To be filed with the Social Security Office nearest to the Employee's Address)
PLEASE PRINT OR TYPE
I. IDENTIFICATION OF PARTIES (To be completed by requesting party)
Employee's Social Security No.
Employee's Name (First, Middle, Last)
Date of Accident:
(Month-Day-Year)
Employee's Address
Employer's Firm Name & Address
Claims-handling entity’s Name & Address
Claims-handling entity File No.
II. EMPLOYEE'S AUTHORIZATION FOR RELEASE (To be completed and dated by employee)
Notice to Employee - This form has been provided to you to supply your AUTHORIZATION FOR RELEASE OF INFORMATION. The Workers' Compensation Act F.S.
440.15(9)(c) requires you to furnish this Authorization. SHOULD YOU REFUSE TO SIGN AND RETURN THIS FORM WITHIN 21 DAYS AFTER THE DATE OF RECEIPT,
YOUR WORKERS' COMPENSATION PAYMENTS MAY STOP until you comply with this request.
To allow determination of the proper amount of workers' compensation payments, I HEREBY AUTHORIZE release of Social Security Benefit information. (A photocopy
can be used in place of original.) This authorization is valid for a period of 12 months from the date signed by employee.
I HAVE REVIEWED, UNDERSTAND, AND ACKNOWLEDGE THE INFORMATION IN THIS SECTION.
Employee's Signature
Employee's Date of Birth:
Date Signed by Employee:
(Month-Day-Year)
(Month-Day-Year)
III. SOCIAL SECURITY INFORMATION (To be completed by Social Security Administration)
Yes If "YES", date applied
1. Has this employee applied for Disability Benefits under 42 U.S.C. Section 423?
No _____ / ______ / _______
2. Has the amount payable under 42 U.S.C. Section 423 or 402 been determined
Yes
Denied
Pending
and benefits commenced?
(a) What was the INITIAL benefit paid to the employee (P.I.A.)?
$ ________________________________
3.
DO NOT INCLUDE SUBSEQUENT COST OF LIVING INCREASES
$ ________________________________
(b) Provide the amount of INITIAL Maximum Family Benefits.
DO NOT INCLUDE SUBSEQUENT COST OF LIVING INCREASES
$ ________________________________
(c) What is 80% of Average Current Earnings used to determine benefits (A.C.E.)?
________________________________
(d) What is the number of auxiliaries or dependents in current month?
4. Has any offset pursuant to 42 U.S.C. Section 424 been taken?
Yes
No
5. If "YES" to Question #4 above, list amount of offset.
$ ________________________________
6. If "YES" to Question #4 above, list the date SSA Offset will end.
________________________________
(MM/YY)
Yes
No
7. Is employee insured for Social Security Retirement Benefits under 42 U.S.C. Section 402 and 405?
SSA REPRESENTATIVE SIGNATURE
DATE:
(Month-Day-Year)
IV. RETURN TO (To be completed by requesting party)
Requestor's Address & Telephone
Signature of Requesting Party
Title of Requesting Party
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-14 (03/2009) Rule 69L-3.025, F.A.C.
RECEIVED BY CLAIMS-
REQUEST FOR SOCIAL SECURITY DISABILITY BENEFIT INFORMATION
HANDLING ENTITY
FLORIDA DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS’ COMPENSATION
(To be filed with the Social Security Office nearest to the Employee's Address)
PLEASE PRINT OR TYPE
I. IDENTIFICATION OF PARTIES (To be completed by requesting party)
Employee's Social Security No.
Employee's Name (First, Middle, Last)
Date of Accident:
(Month-Day-Year)
Employee's Address
Employer's Firm Name & Address
Claims-handling entity’s Name & Address
Claims-handling entity File No.
II. EMPLOYEE'S AUTHORIZATION FOR RELEASE (To be completed and dated by employee)
Notice to Employee - This form has been provided to you to supply your AUTHORIZATION FOR RELEASE OF INFORMATION. The Workers' Compensation Act F.S.
440.15(9)(c) requires you to furnish this Authorization. SHOULD YOU REFUSE TO SIGN AND RETURN THIS FORM WITHIN 21 DAYS AFTER THE DATE OF RECEIPT,
YOUR WORKERS' COMPENSATION PAYMENTS MAY STOP until you comply with this request.
To allow determination of the proper amount of workers' compensation payments, I HEREBY AUTHORIZE release of Social Security Benefit information. (A photocopy
can be used in place of original.) This authorization is valid for a period of 12 months from the date signed by employee.
I HAVE REVIEWED, UNDERSTAND, AND ACKNOWLEDGE THE INFORMATION IN THIS SECTION.
Employee's Signature
Employee's Date of Birth:
Date Signed by Employee:
(Month-Day-Year)
(Month-Day-Year)
III. SOCIAL SECURITY INFORMATION (To be completed by Social Security Administration)
Yes If "YES", date applied
1. Has this employee applied for Disability Benefits under 42 U.S.C. Section 423?
No _____ / ______ / _______
2. Has the amount payable under 42 U.S.C. Section 423 or 402 been determined
Yes
Denied
Pending
and benefits commenced?
(a) What was the INITIAL benefit paid to the employee (P.I.A.)?
$ ________________________________
3.
DO NOT INCLUDE SUBSEQUENT COST OF LIVING INCREASES
$ ________________________________
(b) Provide the amount of INITIAL Maximum Family Benefits.
DO NOT INCLUDE SUBSEQUENT COST OF LIVING INCREASES
$ ________________________________
(c) What is 80% of Average Current Earnings used to determine benefits (A.C.E.)?
________________________________
(d) What is the number of auxiliaries or dependents in current month?
4. Has any offset pursuant to 42 U.S.C. Section 424 been taken?
Yes
No
5. If "YES" to Question #4 above, list amount of offset.
$ ________________________________
6. If "YES" to Question #4 above, list the date SSA Offset will end.
________________________________
(MM/YY)
Yes
No
7. Is employee insured for Social Security Retirement Benefits under 42 U.S.C. Section 402 and 405?
SSA REPRESENTATIVE SIGNATURE
DATE:
(Month-Day-Year)
IV. RETURN TO (To be completed by requesting party)
Requestor's Address & Telephone
Signature of Requesting Party
Title of Requesting Party
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-14 (03/2009) Rule 69L-3.025, F.A.C.
DWC-14 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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