Permanent Total Supplemental Worksheet {DWC-35}

PERMANENT TOTAL SUPPLEMENTAL WORKSHEET DIVISION RECEIVED 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: (Month-Day-Year) SOCIAL SECURITY #: GUARDIAN, If applicable DATE OF BIRTH: (Month-Day-Year) PT ACCEPTANCE/ADJUDICATION DATE: _____________________________ CARRIER PAY DIVISION PAY COMMPUTATION OF SUPPLEMENTAL WEEKLY COMPENSATION AWW: $____________________________ STEP 1: A. $____________________________ Enter employees 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= $____________________________ B. asic 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 (08/2004)