Form DFS-F2-DWC-1 "First Report of Injury or Illness" - Florida

Form DFS-F2-DWC-1 or the "First Report Of Injury Or Illness" is a form issued by the Florida Department of Financial Services.

The form was last revised in October 1, 2016 and is available for digital filing. Download an up-to-date Form DFS-F2-DWC-1 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-1 "First Report of Injury or Illness" - Florida

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RECEIVED BY
FIRST REPORT OF INJURY OR ILLNESS
SENT TO DIVISION DATE
DIVISION RECEIVED DATE
CLAIMS-HANDLING ENTITY
FLORIDA DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
For assistance call 1-800-342-1741
or contact your local EAO Office
PLEASE PRINT OR TYPE
EMPLOYEE INFORMATION
NAME (First, Middle, Last)
Social Security Number
Date of Accident (Month-Day-Year)
Time of Accident
AM
PM
HOME ADDRESS
EMPLOYEE'S DESCRIPTION OF ACCIDENT (Include Cause of Injury)
Street/Apt #: _________________________________________________________
City: _________________________ State: _______________ Zip: ______________
TELEPHONE
Area Code
Number
OCCUPATION
INJURY/ILLNESS THAT OCCURRED
PART OF BODY AFFECTED
DATE OF BIRTH
SEX
_________ / _________ / _________
M
F
EMPLOYER INFORMATION
FEDERAL I.D. NUMBER (FEIN)
DATE FIRST REPORTED (Month/Day/Year)
COMPANY NAME: ___________________________________________________
D. B. A.: ____________________________________________________________
NATURE OF BUSINESS
POLICY/MEMBER NUMBER
Street: _____________________________________________________________
City: _________________________ State: _______________ Zip: ______________
TELEPHONE
Area Code
Number
DATE EMPLOYED
PAID FOR DATE OF INJURY
_________ / _________ / _________
YES
NO
LAST DATE EMPLOYEE WORKED
WILL YOU CONTINUE TO PAY WAGES INSTEAD OF
EMPLOYER'S LOCATION ADDRESS (If different)
WORKERS' COMP?
YES
_________ / _________ / _________
Street: _____________________________________________________________
LAST DAY WAGES WILL BE PAID INSTEAD OF
RETURNED TO WORK
YES
NO
City: ________________________ State: _______________ Zip: ______________
WORKERS' COMP
IF YES, GIVE DATE
LOCATION # (If applicable) ____________________________________________
_________ / _________ / _________
_________ / _________ / _________
DATE OF DEATH (If applicable)
RATE OF PAY
HR
WK
PLACE OF ACCIDENT (Street, City, State, Zip)
_________ / _________ / _________
$ _________________ PER
DAY
MO
Street: _____________________________________________________________
AGREE WITH DESCRIPTION OF ACCIDENT?
City: _________________________ State: _______________ Zip: ______________
Number of hours per day
______________________
YES
NO
Number of hours per week
______________________
COUNTY OF ACCIDENT ______________________________________________
Number of days per week
______________________
Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program, files a
NAME, ADDRESS AND TELEPHONE
statement of claim containing any false or misleading information commits insurance fraud, punishable as provided in s. 817.234. Section 440.105(7),
OF PHYSICIAN OR HOSPITAL
F.S.
I have reviewed, understand and acknowledge the above statement.
__________________________________________________________________
_______________________________________________
EMPLOYEE SIGNATURE (If available to sign)
DATE
__________________________________________________________________
_______________________________________________
EMPLOYER SIGNATURE
DATE
AUTHORIZED BY EMPLOYER
YES
NO
CLAIMS-HANDLING ENTITY INFORMATION
1(a) Denied Case - DWC-12, Notice of Denial Attached
2. Medical Only which became Lost Time Case (Complete all required information in #3)
TH
1(b) Indemnity Only Denied Case - DWC-12, Notice of Denial Attached
Employee’s 8
Day of Disability
_________ / _________ / _________
TH
Entity’s Knowledge of 8
Day of Disability _________ /_________ / _________
3. Lost Time Case - 1st day of disability _________ / _________ / _________
Full Salary in lieu of comp?
YES
Full Salary End Date ________/ ________ / ________
Date First Payment Mailed _________ / _________ / _________
AWW ____________________________
Comp Rate ____________________________
T.T.
T.T. - 80%
T.P.
I.B.
P.T.
DEATH
SETTLEMENT ONLY
st
st
Penalty Amount Paid in 1
Payment $___________
Interest Amount Paid in 1
Payment $__________
REMARKS:
INSURER NAME
CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE
EMPLOYEE'S CLASS CODE
EMPLOYER'S NAICS CODE
INSURER CODE #
SERVICE CO/TPA CODE #
CLAIMS-HANDLING ENTITY FILE #
Form DFS-F2-DWC-1 (10/2016) Rule 69L-3.025, F.A.C.
RECEIVED BY
FIRST REPORT OF INJURY OR ILLNESS
SENT TO DIVISION DATE
DIVISION RECEIVED DATE
CLAIMS-HANDLING ENTITY
FLORIDA DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
For assistance call 1-800-342-1741
or contact your local EAO Office
PLEASE PRINT OR TYPE
EMPLOYEE INFORMATION
NAME (First, Middle, Last)
Social Security Number
Date of Accident (Month-Day-Year)
Time of Accident
AM
PM
HOME ADDRESS
EMPLOYEE'S DESCRIPTION OF ACCIDENT (Include Cause of Injury)
Street/Apt #: _________________________________________________________
City: _________________________ State: _______________ Zip: ______________
TELEPHONE
Area Code
Number
OCCUPATION
INJURY/ILLNESS THAT OCCURRED
PART OF BODY AFFECTED
DATE OF BIRTH
SEX
_________ / _________ / _________
M
F
EMPLOYER INFORMATION
FEDERAL I.D. NUMBER (FEIN)
DATE FIRST REPORTED (Month/Day/Year)
COMPANY NAME: ___________________________________________________
D. B. A.: ____________________________________________________________
NATURE OF BUSINESS
POLICY/MEMBER NUMBER
Street: _____________________________________________________________
City: _________________________ State: _______________ Zip: ______________
TELEPHONE
Area Code
Number
DATE EMPLOYED
PAID FOR DATE OF INJURY
_________ / _________ / _________
YES
NO
LAST DATE EMPLOYEE WORKED
WILL YOU CONTINUE TO PAY WAGES INSTEAD OF
EMPLOYER'S LOCATION ADDRESS (If different)
WORKERS' COMP?
YES
_________ / _________ / _________
Street: _____________________________________________________________
LAST DAY WAGES WILL BE PAID INSTEAD OF
RETURNED TO WORK
YES
NO
City: ________________________ State: _______________ Zip: ______________
WORKERS' COMP
IF YES, GIVE DATE
LOCATION # (If applicable) ____________________________________________
_________ / _________ / _________
_________ / _________ / _________
DATE OF DEATH (If applicable)
RATE OF PAY
HR
WK
PLACE OF ACCIDENT (Street, City, State, Zip)
_________ / _________ / _________
$ _________________ PER
DAY
MO
Street: _____________________________________________________________
AGREE WITH DESCRIPTION OF ACCIDENT?
City: _________________________ State: _______________ Zip: ______________
Number of hours per day
______________________
YES
NO
Number of hours per week
______________________
COUNTY OF ACCIDENT ______________________________________________
Number of days per week
______________________
Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program, files a
NAME, ADDRESS AND TELEPHONE
statement of claim containing any false or misleading information commits insurance fraud, punishable as provided in s. 817.234. Section 440.105(7),
OF PHYSICIAN OR HOSPITAL
F.S.
I have reviewed, understand and acknowledge the above statement.
__________________________________________________________________
_______________________________________________
EMPLOYEE SIGNATURE (If available to sign)
DATE
__________________________________________________________________
_______________________________________________
EMPLOYER SIGNATURE
DATE
AUTHORIZED BY EMPLOYER
YES
NO
CLAIMS-HANDLING ENTITY INFORMATION
1(a) Denied Case - DWC-12, Notice of Denial Attached
2. Medical Only which became Lost Time Case (Complete all required information in #3)
TH
1(b) Indemnity Only Denied Case - DWC-12, Notice of Denial Attached
Employee’s 8
Day of Disability
_________ / _________ / _________
TH
Entity’s Knowledge of 8
Day of Disability _________ /_________ / _________
3. Lost Time Case - 1st day of disability _________ / _________ / _________
Full Salary in lieu of comp?
YES
Full Salary End Date ________/ ________ / ________
Date First Payment Mailed _________ / _________ / _________
AWW ____________________________
Comp Rate ____________________________
T.T.
T.T. - 80%
T.P.
I.B.
P.T.
DEATH
SETTLEMENT ONLY
st
st
Penalty Amount Paid in 1
Payment $___________
Interest Amount Paid in 1
Payment $__________
REMARKS:
INSURER NAME
CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE
EMPLOYEE'S CLASS CODE
EMPLOYER'S NAICS CODE
INSURER CODE #
SERVICE CO/TPA CODE #
CLAIMS-HANDLING ENTITY FILE #
Form DFS-F2-DWC-1 (10/2016) Rule 69L-3.025, F.A.C.
DWC-1 Purpose and Use Statement
The collection of the social security number on this form is
specifically authorized by Section 440.185(2), Florida
Statutes. 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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