The forms used in workers' compensation are referred to by both the name of the form and the number. The number is at the bottom left hand side of the form. These forms are required by law and were created by the State of Florida Division of Workers’ Compensation, but they were sent to you by your employer’s insurance carrier. Below is a brief description of the most commonly used forms. If you have any questions about a form you received, call 800 342-1741 or e-mail your question to wceao@myfloridacfo.com. To view a copy of a form click on the name of the form.
First Report
of Injury or Illness (DWC-1)
:
This form is used to document an injury or illness. The top portion
of the form is completed by your employer and sent to the insurance
carrier. If the injury or illness results in 8 or more days of
disability, the insurance carrier completes the bottom portion of
the form and reports the injury or illness to the Division of
Workers’ Compensation. This form contains a fraud statement that you
are required to sign. If you are not available to sign the form, or
if the injury or illness was reported by phone, the insurance
carrier will send you a fraud statement at a later date.
Notice of
Action/Change (DWC-4):
This form is sent to you, your employer and the Division of Workers’
Compensation to advise that the status of your claim has changed.
There is a second page of the form that explains the abbreviations
for the disability types, the suspension reason codes and the
benefit adjustment codes. On the bottom portion of the form there is
a section entitled “Remarks” where you can see written comments
about the action/change.
Notice of
Denial (DWC-12):
This form is used to advise you, your employer and the Division of
Workers Compensation that the insurance carrier is totally or
partially denying your claim. The first section below the employee
and employer information, “Denied Benefits” will list the specific
benefits that are being denied. The next section “Reason for Denial
of Benefits” will give you the insurance carrier’s specific
reason(s) for the denial of benefits.
Florida Workers’
Compensation Uniform Medical Treatment/Status Report Form (DWC-25):
This form is used by your doctor to report to the insurance carrier
the medical status of your claim. The form is very detailed and
requires the doctor to determine if the injury is work related and
that the injury is more than 50% responsible for your need for
treatment. The doctor is also required to address your work status.
You should ask your doctor for a copy of this form and be sure to
provide a copy to your employer.
Employee
Earnings Report (DWC-19):
This form is used to report any income you have while you are
collecting workers’ compensation benefits. The insurance carrier may
periodically request that you complete and return this form. Failure
to complete and return the form within 10 days after you receive it
may result in your benefits being suspended. When you are released
to light duty work the insurance carrier will, within five days of
their knowledge, also mail you the following letter, which explains
your eligibility for Temporary Partial Disability Benefits.
“Your doctor has released you to return to
work, but because of your work-related accident, you have been given
restrictions on the type of work you can now do. Because you have
not reached maximum medical improvement (the date after which your
doctor says your injury will probably not get better), you may
continue receiving workers’ compensation benefits approximately
every two weeks if you are not able to earn at least 80% of the
weekly wages you were making before your injury.
(a) These benefits, called Temporary Partial Disability benefits,
will be paid until:
1. You reach maximum medical improvement or can return to work
without restrictions;
2. You receive the maximum of 104 weeks allowed by law for either
Temporary Total Disability benefits, Temporary Partial Disability
benefits or Training and Education Temporary Total benefits, or 104
weeks for the combined benefits; or
3. You earn 80% or more of the weekly wages you were making at the
time of your accident.
(b) IMPORTANT: Temporary Partial Disability benefits may be stopped
if:
1. You do not notify this office within five (5) business days after
you return to work;
2. You are not working due to your own misconduct on the job;
3. You refuse suitable employment offered to you; or
4. You do not return, if requested, Form DFS-F2-DWC-19, “Employee
Earnings Report”, as adopted in Rule 69L-3.025, F.A.C., to this
claims office within 21 days after you receive it and report the
receipt of any earnings, including Unemployment Compensation or
Social Security benefits. You may be asked to complete, sign, and
return this form once a month.
You are to notify this office immediately if you stop making at
least 80% of your pre-injury weekly wages. However, if you leave
your job without just cause as determined by a judge, your temporary
partial disability benefits will be paid based on the amount of
money you would have earned had you not left work.
For more information about temporary partial disability benefits,
please call the Employee Assistance Ombudsman Office (EAO) with the
Division of Workers’ Compensation at any of its local offices listed
in your “Important Workers’ Compensation Information For Florida
Workers’ brochure, or at 1 (800) 342-1741."
Wage
Statement (DWC-1a):
This form is completed by your employer and sent to the insurance
carrier to report your wages for the 13 weeks prior to your injury
or illness. This is how the insurance carrier determines the amount
of your lost wage benefits.
Request for
Social Security Disability Benefit Information (DWC-14):
This form is used by the insurance carrier to secure your
authorization for the Social Security Administration to release your
Social Security Benefits information to the insurance carrier. If
you fail to complete and return this form upon request, your
benefits may be suspended until you comply.
