Request For Social Security Disability Benefit Information {DWC-14}

RECEIVED BY CLAIMS- REQUEST FOR SOCIAL SECURITY DI SABILITY BENEFIT INFORMATION HANDLING ENTITY FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS COMPENSATION (To be filed with the Social Security Office nearest to the Employees Address) PLEASE PRINT OR TYPE I. IDENTIFICATION OF PARTIES (To be completed by requesting party) Employees Name (First, Middle, Last) Date of Accident: (Month-Day-Year) Employees Social Security No.  Employees Address Employers Firm Name & Address Claims-handling entitys Name & Address Claims-handling entity File No. II. EMPLOYEES AUTHORIZATION FOR RELEASE (To be completed and dated by employee) Notice to Employee - This form has been provided to you to supply your AUTHORIZATION FOR RELEASE OF INFORMATION. The Workers Compensation Act F.S. 440.15(9)(c) requires you to furnish this Authorization. SHOULD YOU REFUSE TO SIGN AND RETURN THIS FORM WITHIN 21 DAYS AFTER THE DATE OF RECEIPT, YOUR WORKERS COMPENSATION PAYMENTS MAY ST OP until you comply with this request. To allow determination of the proper amount of workers compensation payments, I HEREBY AUTHORIZE release of Social Security Be nefit information. (A photocopy can be used in place of original.) This authorization is valid for a period of 12 months from the date signed by employee. I HAVE REVIEWED, UNDERSTAND, AND ACKNOWLEDGE THE INFORMATION IN THIS SECTION. Employees Signature Employees Date of Birth: (Month-Day-Year) Date Signed by Employee: (Month-Day-Year) III. SOCIAL SECURITY INFORMATION (To be completed by Social Security Administration) Yes If "YES", date applied 1. Has this employee applied for Disability Benefits under 42 U.S.C. Section 423? No _____ / ______ / _______ 2. Has the amount payable under 42 U.S.C. Section 423 or 402 been determined and benefits commenced? Yes Denied Pending 3. (a) What was the INITIAL benefit paid to the employee (P.I.A.)? $ ________________________________ DO NOT INCLUDE SUBSEQUENT COST OF LIVING INCREASES (b) Provide the amount of INITIAL Maximum Family Benefits. $ ________________________________ DO NOT INCLUDE SUBSEQUENT COST OF LIVING INCREASES (c) What is 80% of Average Current Earnings used to determine benefits (A.C.E.)? $ ________________________________ (d) What is the number of auxiliaries or dependents in current month? ________________________________ 4. Has any offset pursuant to 42 U.S.C. Section 424 been taken? Yes No 5. If "YES" to Question #4 above, list amount of offset. $ ________________________________ 6. If "YES" to Question #4 above, list the date SSA Offset will end. (MM/YY) ________________________________ 7. Is employee insured for Social Security Retirement Benefits under 42 U.S.C. Section 402 and 405? Yes No SSA REPRESENTATIVE SIGNATURE DATE: (Month-Day-Year) IV. RETURN TO (To be completed by requesting party) Requestors Address & Telephone Signature of Requesting Party Title of Requesting Party 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. Form DFS-F2-DWC-14 (08/2004)