Form DFS-F2-DWC-30 "Authorization and Request for Unemployment Compensation Information" - Florida

What Is Form DFS-F2-DWC-30?

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;
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RECEIVED BY CLAIMS-

AUTHORIZATION AND REQUEST FOR UNEMPLOYMENT COMPENSATION INFORMATION

HANDLING ENTITY

AGENCY FOR WORKFORCE INNOVATION

Unemployment Compensation

Benefit Records

Post Office Box 5750

Tallahassee, FL 32314-5750

FLORIDA DEPARTMENT OF FINANCIAL SERVICES

DIVISION OF WORKERS’ COMPENSATION

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 REQUEST THE AUTHORIZATION AND RELEASE OF UNEMPLOYMENT COMPENSATION ON THE FOLLOWING PERSON

Employer's Case File No.

Employee's Name

(First, Middle, Last)

Claims-handling entity File No.

Name of Employer's Firm

Date of Accident

(Month-Day-Year)

I HEREBY CERTIFY THAT I AM THE EMPLOYER OF RECORD OR THE EMPLOYER’S WORKERS’ COMPENSATION INSURER, OR THEIR

REPRESENTATIVE WITH WHOM A CLAIM FOR BENEFITS UNDER CHAPTER 440 F.S. HAS BEEN MADE.

NAME AND ADDRESS OF EMPLOYER/CLAIMS-HANDLING ENTITY

Signature of Requestor

(REQUESTOR)

Name of Requestor

(please print)

Title of Requestor

TO INSURE DELIVERLY, PLEASE ENCLOSE A SELF-ADDRESSED STAMPED ENVELOPE

EMPLOYEE'S AUTHORIZATION FOR RELEASE OF UNEMPLOYMENT COMPENSATION INFORMATION

NOTE: Section 443.1715, F.S., requires you to furnish this authorization for release of unemployment compensation information for a claimant who has a worker’s compensation claim

pending or is receiving compensation benefits.

The Florida Worker’s Compensation Act provides that worker’s compensation benefits shall be reduced by the amount of the unemployment compensation received pursuant to Section

440.15(10), F.S. To allow determination of the proper amount of workers compensation, I hereby authorize release of unemployment compensation information relative to my account.

THIS AUTHORIZATION IS VALID FOR A PERIOD OF 12 MONTHS FROM THE DATE SIGNED.

EMPLOYEE'S SIGNATURE

DATE SIGNED:

(Month-Day-Year)

UNEMPLOYMENT COMPENSATION INFORMATION (To be completed by the Agency for Workforce Innovation)

HAS EMPLOYEE FILED FOR UNEMPLOYMENT COMPENSATION?

YES

IF YES, WHAT IS THE STATUS OF THE CLAIM?

Eligible (See attached record of payments)

Denied

Pending (Re-submit request in 90 days)

Records have been officially purged

COMMENTS:

DATE:

OFFICIAL SIGNATURE

TITLE

(Month-Day-Year)

Form DFS-F2-DWC-30 (03/2009) RULE 69L-3.025, F.A.C.

RECEIVED BY CLAIMS-

AUTHORIZATION AND REQUEST FOR UNEMPLOYMENT COMPENSATION INFORMATION

HANDLING ENTITY

AGENCY FOR WORKFORCE INNOVATION

Unemployment Compensation

Benefit Records

Post Office Box 5750

Tallahassee, FL 32314-5750

FLORIDA DEPARTMENT OF FINANCIAL SERVICES

DIVISION OF WORKERS’ COMPENSATION

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 REQUEST THE AUTHORIZATION AND RELEASE OF UNEMPLOYMENT COMPENSATION ON THE FOLLOWING PERSON

Employer's Case File No.

Employee's Name

(First, Middle, Last)

Claims-handling entity File No.

Name of Employer's Firm

Date of Accident

(Month-Day-Year)

I HEREBY CERTIFY THAT I AM THE EMPLOYER OF RECORD OR THE EMPLOYER’S WORKERS’ COMPENSATION INSURER, OR THEIR

REPRESENTATIVE WITH WHOM A CLAIM FOR BENEFITS UNDER CHAPTER 440 F.S. HAS BEEN MADE.

NAME AND ADDRESS OF EMPLOYER/CLAIMS-HANDLING ENTITY

Signature of Requestor

(REQUESTOR)

Name of Requestor

(please print)

Title of Requestor

TO INSURE DELIVERLY, PLEASE ENCLOSE A SELF-ADDRESSED STAMPED ENVELOPE

EMPLOYEE'S AUTHORIZATION FOR RELEASE OF UNEMPLOYMENT COMPENSATION INFORMATION

NOTE: Section 443.1715, F.S., requires you to furnish this authorization for release of unemployment compensation information for a claimant who has a worker’s compensation claim

pending or is receiving compensation benefits.

The Florida Worker’s Compensation Act provides that worker’s compensation benefits shall be reduced by the amount of the unemployment compensation received pursuant to Section

440.15(10), F.S. To allow determination of the proper amount of workers compensation, I hereby authorize release of unemployment compensation information relative to my account.

THIS AUTHORIZATION IS VALID FOR A PERIOD OF 12 MONTHS FROM THE DATE SIGNED.

EMPLOYEE'S SIGNATURE

DATE SIGNED:

(Month-Day-Year)

UNEMPLOYMENT COMPENSATION INFORMATION (To be completed by the Agency for Workforce Innovation)

HAS EMPLOYEE FILED FOR UNEMPLOYMENT COMPENSATION?

YES

IF YES, WHAT IS THE STATUS OF THE CLAIM?

Eligible (See attached record of payments)

Denied

Pending (Re-submit request in 90 days)

Records have been officially purged