Fill and Sign the Faq for Injured Workers Florida Department of Financial Form

NOTICE OF ACTION/CHANGE SENT TO DIVISION DATE DIVISION RECEIVED DATE DIVISION OF WORKERS' COMPENSATION Attention: Information Management 200 East Gaines Street Tallahassee, FL 32399-4226 For assistance call 1-800-342-1741 or contact your local EAO Office COMPLETE ALL APPLICABLE SECTIONS BEFORE FILING WITH THE DIVISION PLEASE PRINT OR TYPE SOCIAL SECURITY NUMBER EMPLOYEE NAME (First, Middle, Last) DATE OF ACCIDENT (Month-Day-Year) INDICATE ONLY ACTION OR CHANGE - PLEASE REFER TO KEY FOR DWC-4 TYPES/CODES ON REVERSE SIDE ALL INDEMNITY SUSPENDED: INDEMNITY REINSTATED AFTER SUSPENSION: EFFECTIVE DATE EFFECTIVE DATE _______ - _______ - ______ _______ - _______ - ______ REASON CODE: DISABILITY TYPE: ______________________ ______________________ RELEASED TO RETURN TO WORK DATE: ACTUAL RETURN TO WORK DATE: DATE FINAL SETTLEMENT ORDER MAILED: OVERALL MMI DATE: _________ - _________ - _________ _________ - _________ - _________ _________ - _________ - _________ _________ - _________- _________ RESTRICTIONS?: YES NO RESTRICTIONS?: YES NO PI RATING: __________ % BAW DATE OF DEATH _________ - _________ - _________ PERMANENT IMPAIRMENT BENEFITS (D/A'S PRIOR TO 01/01/94): IMPAIRMENT INCOME BENEFITS (D/A'S ON OR AFTER 01/01/94): DATE PAID: START DATE: _________ - _________ - _________ _________ - _________ - _________ WEEKLY RATE: $ _________________ TOTAL NUMBER OF WEEKS OF ENTITLEMENT: __________________ PERMANENT DATE ACCEPTED/ADJUDICATED _________ - _________- _________ AVERAGE WEEKLY WAGE AND/OR COMPENSATION RATE AMENDMENTS: TOTAL: WEEKLY PT SUPPLEMENTAL RATE WEEKLY PT SUPP EFFECTIVE DATE $ ______________________________ _________ - _________- _________ PREVIOUS AWW: PREVIOUS COMP RATE: $ _______________________________ $ _______________________________ BENEFIT ADJUSTMENTS AMENDED AWW: $ _______________________________ BENEFIT ADJUSTMENT CODE DISABILITY TYPE ADJUSTED WEEKLY ADJ AMOUNT $ EFFECTIVE DATE ADJUSTMENT END DATE __________ __________ __________ __________ __________ BENEFIT ADJUSTMENT CODE DISABILITY TYPE ADJUSTED WEEKLY ADJ AMOUNT $ EFFECTIVE DATE ADJUSTMENT END DATE __________ __________ __________ __________ __________ AMENDED COMP RATE: RETROACTIVE TO D/A: IF NO, GIVE EFFECTIVE DATE: $ _______________________________ YES NO _________ - _________- _________ CORRECTIONS OF: SOCIAL SECURITY NUMBER/CORRECT #: DATE OF ACCIDENT/CORRECT DATE: ________________________________________________ _______________ - _______________ - ______________ CLASS CODE EMPLOYEE’S NAME/CORRECT NAME: CLAIMS-HANDLING ENTITY: ________________________________________________ ________________________________________________ NAICS CODE REMARKS: ________________________________________________________________________\ ______________________________________________________________________________ ________________________________________________________________________\ ______________________________________________________________________________ ________________________________________________________________________\ ______________________________________________________________________________ CC: INSURER NAME INSURER CODE # DATE PREPARED: (Month-Day-Year) _________ - _________ - _________ CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE SERVICE CO/TPA CODE # CLAIMS-HANDLING ENTITY FILE # Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-i nsured program, files a statement of claim containing any false or misleading information commits insurance fraud, punishable as provide d in s. 817.234. Section 440.105(7), F.S. Form DFS-F2-DWC-4 (03/2009) Rule 69L-3.025, F.A.C. KEY FOR DFS-F2-DWC-4 TYPES / CODES DISABILITY TYPES: TT - Temporary Total Disability Benefits DWC-4 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.