Request For Wage Loss-Temporary Partial Benefits {DWC-3}

Form DFS-F2-DWC-3 - REQUEST FOR WAGE LOSS/TEMPORARY PARTIAL BENEFITS. This Florida Department of Financial Services form is used by injured employees to claim wage loss or temporary partial disability (TPD) benefits under the state’s workers’ compensation system. Employees must complete and submit the form every two weeks to their claims-handling entity, reporting wages earned (if employed) or documenting job search efforts if unemployed. The form requires disclosure of Social Security and unemployment compensation benefits, authorization to release related records, and certification of truthful reporting. Employers/insurers use the form to calculate benefits owed, apply offsets, and process payment. A separate Work Search Report section must be completed by employees not currently employed, listing job applications and contacts made during the two-week claim period. Rule 69L-3.025, F.A.C. www.FormsWorkflow.com