Florida > Workers Comp
First Report Injury Or Illness DWC-1 - Florida
| First Report Injury Or Illness Form. This is a Florida form and can be used in Workers Comp . |
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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 Report all deaths within 24 hours 1-800-219-8953 or (850) 922-8953 PLEASE PRINT OR TYPE EYMEPEL INO FORMATION NAME (First, Middle, Last) Social Security Number Date of Accident (Month-Day-Year) Time of Accident AM PM HOME ADDRESS EMPLOYEES 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 EMPLOYERS LOCATION ADDRESS (If different) WORKERS COMP? YES _________ / _________ / _________ Street: _____________________________________________________________ RETURNED TO WORK YES NO LAST DAY WAGES WILL BE PAID INSTEAD OF City: ________________________ State: _______________ Zip: ______________ IF YES, GIVE DATE WORKERS COMP LOCATION # (If applicable) ____________________________________________ _________ / _________ / _________ _________ / _________ / _________ DATE OF DEATH (If applicable) RATE OF PAY HR WK PLACE OF ACCIDENT (Street, City, State, Zip) _________ / _________ / _________ $ _________________ PER Street: _____________________________________________________________ DAY MO 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 statement of NAME, ADDRESS AND TELEPHONE claim containing any false or misleading information commits insurance fraud, punishable as provided in s. 817.234. Section 44 0.105(7), F.S. OF PHYSICIAN OR HOSPITAL 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) 1(b) Indemnity Only Denied Case - DWC-12, Notice of Denial Attached Employees 8TH Day of Disability _________ / _________ / _________ TH Entitys 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 INSURER CODE # EMPLOYEES CLASS CODE EMPLOYERS NAICS CODE SERVICE CO/TPA CODE # CLAIMS-HANDLING ENTITY FILE # Form DFS-F2-DWC-1 (08/2004)
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