Form DFS-F2-DWC-40 "Statement of Quarterly Earnings for Supplemental Income Benefits" - Florida

What Is Form DFS-F2-DWC-40?

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-40 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-40 "Statement of Quarterly Earnings for Supplemental Income Benefits" - Florida

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CLAIMS-HANDLING ENTITY
SENT TO DIVISION
DIVISION RECEIVED
STATEMENT OF QUARTERLY EARNINGS
RECEIVED DATE
DATE
DATE
FOR SUPPLEMENTAL INCOME BENEFITS
DATES OF ACCIDENT ON OR AFTER JANUARY 1, 1984 THROUGH SEPTEMBER 30,
2003
FLORIDA DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
1-800-342-1741 or contact your local office for assistance
PLEASE PRINT OR TYPE
A
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (First, Middle, Last)
DATE OF ACCIDENT:
Month-Day-Year)
ACCIDENT EMPLOYER NAME
FILING PERIOD:
___________________________________ THROUGH ___________________________________
BEGINNING DATE
ENDING DATE
B
NOTICE TO EMPLOYEE: Report all wages earned during the filing period in the area provided below.
PLEASE CHECK APPROPRIATE BOXES:
*** See instructions on the back side of this form ***
I RETURNED TO WORK BUT MY REDUCED WAGES WERE A DIRECT RESULT OF MY IMPAIRMENT FROM THIS INJURY.
DURING ANY WEEKS I WAS NOT EMPLOYED, I HAVE IN GOOD FAITH ATTEMPTED TO OBTAIN EMPLOYMENT, WHICH I AM ABLE TO DO.
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.
I HAVE REVIEWED, UNDERSTAND, AND ACKNOWLEDGE THAT THE INFORMATION PROVIDED ON THIS FORM AND ANY ATTACHMENTS IS TRUE AND CORRECT.
EMPLOYEE SIGNATURE: _____________________________________________________________________________________________ DATE: _________________________________
C
CURRENT RATE OF PAY: $_______________PER
GRATUITIES AS
(CLAIMS-
FRINGE BENEFITS (employee rec'd)
HR
WK
DAY
MO
REPORTED TO
HANDLING
THE EMPLOYER
HOURS PER DAY ____________
HOURS PER WEEK__________
DAYS PER WEEK __________
ENTITY
EMPLOYER COST ONLY
IN WRITING AS
WEEK
# OF DAYS
# OF HOURS
USE ONLY)
TAXABLE
WEEK
WORKED
WORKED
GROSS
DEEMED
HEALTH
RENT/
NO.
FROM
TO
THAT WEEK
THAT WEEK
PAY
INCOME
WAGES
INSURANCE
HOUSING
1
2
3
4
5
6
7
8
9
10
11
12
13
AREA BELOW FOR CLAIMS-HANDLING ENTITY USE ONLY
1
2
3
4
5
TOTALS:
MONTHLY SUPP. BENEFITS CALCULATION
BENEFIT ADJUSTMENT DUE TO OVERPAYMENT
$
D
Pre-injury AWW x 4.3 x 0.80 =
Adjusted Monthly Wage
$
Amount Paid for ____/____/____ thru ____/____/____
TOTAL OF
Minus (Current AWW x 4.3) =
Current Monthly Wage
1+2+3+4+5
$
Paid on
______/______/______
$
Equals Total Monthly
Wage Loss
$
Amount Due for ____/____/____ thru ____/____/____
$
DIVIDE BY #
Multiplied by 0.80 =
Monthly S.I.B. Payable
Total Amount of Overpayment Credit
OF WEEKS IN
$
$
EQUALS
FILING
PERIOD
Payment Period
Amount of Overpayment Credit applied per month
CURRENT
$
________/________/________ thru ________/________/________
(Not to EXCEED 20% of Monthly Payment)
$
AVERAGE
Subject to Maximum Payable
Monthly Adjusted Amount due for
WEEKLY
at Comp Rate __________ x 4.3
$
______/______/______ thru ______/______/______
$
WAGE
Payment Amount for Initial
Remaining Overpayment Credit
Month
$
$
ADJUSTER NAME:
Payment for filing period denied. See attached Notice of Denial.
INSURER CODE #
DATE PREPARED
RETURN THIS FORM TO: CLAIMS-HANDLING ENTITY NAME, ADDRESS AND TELEPHONE#
SERVICE CO/TPA CODE #
CLAIMS-HANDLING ENTITY FILE #
Form DFS-F2-DWC-40 (03/2009)
Rule 69L-3.025, F.A.C.
CLAIMS-HANDLING ENTITY
SENT TO DIVISION
DIVISION RECEIVED
STATEMENT OF QUARTERLY EARNINGS
RECEIVED DATE
DATE
DATE
FOR SUPPLEMENTAL INCOME BENEFITS
DATES OF ACCIDENT ON OR AFTER JANUARY 1, 1984 THROUGH SEPTEMBER 30,
2003
FLORIDA DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
1-800-342-1741 or contact your local office for assistance
PLEASE PRINT OR TYPE
A
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (First, Middle, Last)
DATE OF ACCIDENT:
Month-Day-Year)
ACCIDENT EMPLOYER NAME
FILING PERIOD:
___________________________________ THROUGH ___________________________________
BEGINNING DATE
ENDING DATE
B
NOTICE TO EMPLOYEE: Report all wages earned during the filing period in the area provided below.
PLEASE CHECK APPROPRIATE BOXES:
*** See instructions on the back side of this form ***
I RETURNED TO WORK BUT MY REDUCED WAGES WERE A DIRECT RESULT OF MY IMPAIRMENT FROM THIS INJURY.
DURING ANY WEEKS I WAS NOT EMPLOYED, I HAVE IN GOOD FAITH ATTEMPTED TO OBTAIN EMPLOYMENT, WHICH I AM ABLE TO DO.
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.
I HAVE REVIEWED, UNDERSTAND, AND ACKNOWLEDGE THAT THE INFORMATION PROVIDED ON THIS FORM AND ANY ATTACHMENTS IS TRUE AND CORRECT.
EMPLOYEE SIGNATURE: _____________________________________________________________________________________________ DATE: _________________________________
C
CURRENT RATE OF PAY: $_______________PER
GRATUITIES AS
(CLAIMS-
FRINGE BENEFITS (employee rec'd)
HR
WK
DAY
MO
REPORTED TO
HANDLING
THE EMPLOYER
HOURS PER DAY ____________
HOURS PER WEEK__________
DAYS PER WEEK __________
ENTITY
EMPLOYER COST ONLY
IN WRITING AS
WEEK
# OF DAYS
# OF HOURS
USE ONLY)
TAXABLE
WEEK
WORKED
WORKED
GROSS
DEEMED
HEALTH
RENT/
NO.
FROM
TO
THAT WEEK
THAT WEEK
PAY
INCOME
WAGES
INSURANCE
HOUSING
1
2
3
4
5
6
7
8
9
10
11
12
13
AREA BELOW FOR CLAIMS-HANDLING ENTITY USE ONLY
1
2
3
4
5
TOTALS:
MONTHLY SUPP. BENEFITS CALCULATION
BENEFIT ADJUSTMENT DUE TO OVERPAYMENT
$
D
Pre-injury AWW x 4.3 x 0.80 =
Adjusted Monthly Wage
$
Amount Paid for ____/____/____ thru ____/____/____
TOTAL OF
Minus (Current AWW x 4.3) =
Current Monthly Wage
1+2+3+4+5
$
Paid on
______/______/______
$
Equals Total Monthly
Wage Loss
$
Amount Due for ____/____/____ thru ____/____/____
$
DIVIDE BY #
Multiplied by 0.80 =
Monthly S.I.B. Payable
Total Amount of Overpayment Credit
OF WEEKS IN
$
$
EQUALS
FILING
PERIOD
Payment Period
Amount of Overpayment Credit applied per month
CURRENT
$
________/________/________ thru ________/________/________
(Not to EXCEED 20% of Monthly Payment)
$
AVERAGE
Subject to Maximum Payable
Monthly Adjusted Amount due for
WEEKLY
at Comp Rate __________ x 4.3
$
______/______/______ thru ______/______/______
$
WAGE
Payment Amount for Initial
Remaining Overpayment Credit
Month
$
$
ADJUSTER NAME:
Payment for filing period denied. See attached Notice of Denial.
INSURER CODE #
DATE PREPARED
RETURN THIS FORM TO: CLAIMS-HANDLING ENTITY NAME, ADDRESS AND TELEPHONE#
SERVICE CO/TPA CODE #
CLAIMS-HANDLING ENTITY FILE #
Form DFS-F2-DWC-40 (03/2009)
Rule 69L-3.025, F.A.C.
STATEMENT OF QUARTERLY EARNINGS FOR SUPPLEMENTAL INCOME BENEFITS
SOCIAL SECURITY NUMBER
EMPLOYEE NAME (First, Middle, Last)
DATE OF ACCIDENT:
Month-Day-Year)
INSTRUCTIONS:
(1)
Fill out Sections B and C on the front of this form.
Use the form that has the first two lines on the front of the form with your name, etc. already
completed. List any money you earned during the 13 weeks for the filing period shown on the
second line.
(2)
Attach copies of paycheck stubs, statements from your employer(s), or any other documentation
you may have of your earnings during the filing period.
(3)
If you have no earnings in a particular week, put down $0 for that week.
(4)
In the boxes below, list all employers you may worked for during the filing period, and the
addresses, phone numbers and dates you were employed.
(5)
Sign and send the completed form to the Insurer or Claims-handling entity name and address
noted in the lower right-hand corner on the front of this form.
(6)
Section 440.15(2), Florida Statutes, requires you to return this form in a timely manner and the
failure to return this form may result in a delay in the payment of benefits.
A Form DFS-F2-DWC-40, Statement of Quarterly Earnings for Supplemental Income Benefits, must
be submitted at the end of every three months in order to receive these benefits.
NAME OF EMPLOYER(S) DURING THIS FILING PERIOD
Employer
Employer
Employer
Date(s)
Name
Address
Phone
Employed
Form DFS-F2-DWC-40 (03/2009) Rule 69L-3.025, F.A.C.
DWC-40 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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