Form DFS-F2-DWC-49 "Aggregate Claims Administration Change Report" - Florida

Form DFS-F2-DWC-49 or the "Aggregate Claims Administration Change Report" is a form issued by the Florida Department of Financial Services.

Download a PDF version of the Form DFS-F2-DWC-49 down below or find it on the Florida Department of Financial Services Forms website.

ADVERTISEMENT

Download Form DFS-F2-DWC-49 "Aggregate Claims Administration Change Report" - Florida

852 times
Rate
(4.3 / 5) 43 votes
SENT TO DIVISION
DIVISION RECEIVED
AGGREGATE CLAIMS ADMINISTRATION CHANGE REPORT
DATE
DATE
FLORIDA DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
200 East Gaines Street
Tallahassee, FL 32399-4226
PLEASE PRINT OR TYPE
CLAIMS-ADMINISTRATOR CHANGED FROM:
CLAIMS-ADMINISTRATOR CHANGED TO:
NAME OF SERVICING CO./TPA:
__________________________________
NAME OF SERVICING CO./TPA:
__________________________________
ADDRESS: ____________________________________________________
ADDRESS: ____________________________________________________
______________________________________________________
______________________________________________________
TELEPHONE: __________________________________________________
TELEPHONE: __________________________________________________
SERVICING CO./TPA CODE #: ____________________________________
SERVICING CO./TPA CODE #: ____________________________________
NAME OF INSURER, FUND, SELF-INSURED EMPLOYER:
NAME OF INSURER, FUND, SELF-INSURED EMPLOYER:
_________________________________________________
_________________________________________________
INSURER CODE #: ______________________________________________
INSURER CODE #: ______________________________________________
EFFECTIVE DATE OF THE CHANGE IN CLAIMS ADMINISTRATION: _______________________________________________________________________
ALL DATES OF ACCIDENT
DATE(S) OF ACCIDENT ON OR AFTER EFFECTIVE DATE
THIS FORM IS DUE WITHIN 30 DAYS OF THE EFFECTIVE DATE OF THE CHANGE IN CLAIMS ADMINISTRATION
DATE OF ACCIDENT
SOCIAL SECURITY NUMBER
EMPLOYEE NAME
EMPLOYER
(First, Middle, Last)
(Month-/Day/Year)
INSURER NAME:
PLEASE ATTACH ADDITIONAL PAGE(S) OF THIS FORM IF NECESSARY,
OR A LISTING IDENTICAL IN FORMAT (EMPLOYEE, SSN, D/A,
CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE
EMPLOYER)
INSURER CODE #
SERVICE CO./TPA CODE #
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-49 (03/2009) Rule 69L-3.025, F.A.C.
SENT TO DIVISION
DIVISION RECEIVED
AGGREGATE CLAIMS ADMINISTRATION CHANGE REPORT
DATE
DATE
FLORIDA DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
200 East Gaines Street
Tallahassee, FL 32399-4226
PLEASE PRINT OR TYPE
CLAIMS-ADMINISTRATOR CHANGED FROM:
CLAIMS-ADMINISTRATOR CHANGED TO:
NAME OF SERVICING CO./TPA:
__________________________________
NAME OF SERVICING CO./TPA:
__________________________________
ADDRESS: ____________________________________________________
ADDRESS: ____________________________________________________
______________________________________________________
______________________________________________________
TELEPHONE: __________________________________________________
TELEPHONE: __________________________________________________
SERVICING CO./TPA CODE #: ____________________________________
SERVICING CO./TPA CODE #: ____________________________________
NAME OF INSURER, FUND, SELF-INSURED EMPLOYER:
NAME OF INSURER, FUND, SELF-INSURED EMPLOYER:
_________________________________________________
_________________________________________________
INSURER CODE #: ______________________________________________
INSURER CODE #: ______________________________________________
EFFECTIVE DATE OF THE CHANGE IN CLAIMS ADMINISTRATION: _______________________________________________________________________
ALL DATES OF ACCIDENT
DATE(S) OF ACCIDENT ON OR AFTER EFFECTIVE DATE
THIS FORM IS DUE WITHIN 30 DAYS OF THE EFFECTIVE DATE OF THE CHANGE IN CLAIMS ADMINISTRATION
DATE OF ACCIDENT
SOCIAL SECURITY NUMBER
EMPLOYEE NAME
EMPLOYER
(First, Middle, Last)
(Month-/Day/Year)
INSURER NAME:
PLEASE ATTACH ADDITIONAL PAGE(S) OF THIS FORM IF NECESSARY,
OR A LISTING IDENTICAL IN FORMAT (EMPLOYEE, SSN, D/A,
CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE
EMPLOYER)
INSURER CODE #
SERVICE CO./TPA CODE #
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-49 (03/2009) Rule 69L-3.025, F.A.C.
DWC-49 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.
ADVERTISEMENT
Page of 2