Form DFS-F2-DWC-35 "Permanent Total Supplemental Worksheet" - Florida

Form DFS-F2-DWC-35 is a Florida Department of Financial Services form also known as the "Permanent Total Supplemental Worksheet". The latest edition of the form was released in March 1, 2009 and is available for digital filing.

Download an up-to-date Form DFS-F2-DWC-35 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-35 "Permanent Total Supplemental Worksheet" - Florida

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DIVISION RECEIVED
PERMANENT TOTAL SUPPLEMENTAL WORKSHEET
SENT TO DIVISION DATE
DATE
FLORIDA DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
200 East Gaines Street
Tallahassee, FL 32399-4224
PLEASE PRINT OR TYPE
EMPLOYEE NAME, ADDRESS & TELEPHONE #:
DATE OF ACCIDENT:
SOCIAL SECURITY #:
(Month-Day-Year)
GUARDIAN, If applicable
DATE OF BIRTH:
(Month-Day-Year)
PT ACCEPTANCE/ADJUDICATION DATE: _____________________________
CARRIER PAY
DIVISION PAY
COMPUTATION OF SUPPLEMENT AL WEEKLY COMPENSATION
AWW: $____________________________
STEP 1: A.
$____________________________ Enter employee’s compensation rate in accordance with the Law in effect on the date of accident.
B. x
$____________________________ Amount of 5% supplemental authorized (3% for dates of accident on or after October 1, 2003)
C. =
$____________________________ Basic Weekly Increase
D. x
$ ___________________________
Number of CALENDAR years since the date of accident
Subtract year of accident from year of PT Acceptance/Adjudication
E. =
$____________________________ Total weekly supplemental – Enter below in (A1)
STEP 2: A.
$____________________________ (Enter the figure from STEP 1A)
B. +
$____________________________ (Enter the figure form STEP 1E)
C. =
$____________________________ (TOTAL – cannot exceed maximum for appropriate year)
THE MAXIMUM WEEKLY COMPENSATION RATE:
1. $_______________ per week, beginning ____________________
4. $_______________ per week, beginning ____________________
2. $_______________ per week, beginning ____________________
5. $_______________ per week, beginning ____________________
3. $_______________ per week, beginning ____________________
6. $_______________ per week, beginning ____________________
STEP 3: Weekly supplemental divided by; 7 x total number of days in year. Combine yearly amounts to get total initial payment due to claimant.
(A1)
Beginning Date
Ending Date
(B1)
(C1)
Comments
Weekly Supplemental
(MM/DD/YY)
(MM/DD/YY)
Total Number of Days
Total Amount
(if any)
Rate
(A1 divided by 7 x B1 = C1)
TOTAL INITIAL PAYMENT $___________________
First Regular Payment Amount
$_______________________________
Payment Date
___________________
(Weekly Amount x 4 = Division Pay)
(Weekly Amount x 2 = Carrier Pay)
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.
INSURER CODE
ADJUSTER NAME:
INSURER NAME:
CLAIMS-HANDLING ENTITY NAME, ADDRESS &
TELEPHONE
SERVICE CO./TPA CODE #
DATE PREPARED:
(Month-Day-Year)
Form DFS-F2-DWC-35 (03/2009) 69L-3.025, F.A.C.
DIVISION RECEIVED
PERMANENT TOTAL SUPPLEMENTAL WORKSHEET
SENT TO DIVISION DATE
DATE
FLORIDA DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
200 East Gaines Street
Tallahassee, FL 32399-4224
PLEASE PRINT OR TYPE
EMPLOYEE NAME, ADDRESS & TELEPHONE #:
DATE OF ACCIDENT:
SOCIAL SECURITY #:
(Month-Day-Year)
GUARDIAN, If applicable
DATE OF BIRTH:
(Month-Day-Year)
PT ACCEPTANCE/ADJUDICATION DATE: _____________________________
CARRIER PAY
DIVISION PAY
COMPUTATION OF SUPPLEMENT AL WEEKLY COMPENSATION
AWW: $____________________________
STEP 1: A.
$____________________________ Enter employee’s compensation rate in accordance with the Law in effect on the date of accident.
B. x
$____________________________ Amount of 5% supplemental authorized (3% for dates of accident on or after October 1, 2003)
C. =
$____________________________ Basic Weekly Increase
D. x
$ ___________________________
Number of CALENDAR years since the date of accident
Subtract year of accident from year of PT Acceptance/Adjudication
E. =
$____________________________ Total weekly supplemental – Enter below in (A1)
STEP 2: A.
$____________________________ (Enter the figure from STEP 1A)
B. +
$____________________________ (Enter the figure form STEP 1E)
C. =
$____________________________ (TOTAL – cannot exceed maximum for appropriate year)
THE MAXIMUM WEEKLY COMPENSATION RATE:
1. $_______________ per week, beginning ____________________
4. $_______________ per week, beginning ____________________
2. $_______________ per week, beginning ____________________
5. $_______________ per week, beginning ____________________
3. $_______________ per week, beginning ____________________
6. $_______________ per week, beginning ____________________
STEP 3: Weekly supplemental divided by; 7 x total number of days in year. Combine yearly amounts to get total initial payment due to claimant.
(A1)
Beginning Date
Ending Date
(B1)
(C1)
Comments
Weekly Supplemental
(MM/DD/YY)
(MM/DD/YY)
Total Number of Days
Total Amount
(if any)
Rate
(A1 divided by 7 x B1 = C1)
TOTAL INITIAL PAYMENT $___________________
First Regular Payment Amount
$_______________________________
Payment Date
___________________
(Weekly Amount x 4 = Division Pay)
(Weekly Amount x 2 = Carrier Pay)
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.
INSURER CODE
ADJUSTER NAME:
INSURER NAME:
CLAIMS-HANDLING ENTITY NAME, ADDRESS &
TELEPHONE
SERVICE CO./TPA CODE #
DATE PREPARED:
(Month-Day-Year)
Form DFS-F2-DWC-35 (03/2009) 69L-3.025, F.A.C.
DWC-35 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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