Florida Regulations 69L-3.025

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§ 69L-3.025 Forms


(1) The following forms are to be used with this rule chapter and are hereby incorporated by reference:

(a) Form DFS-F2-DWC-1 8/04 First Report of Injury or Illness (b) Form IA-1 1/1/02 Workers' Compensation - First report of Injury or Illness - For use only by entities approved to transmit electronic First Reports of injury to the Division (c) Form DFS-F2-DWC-1a 8/04 Wage Statement (d) Form DFS-F2-DWC-3 8/04 Request for Wage Loss/Temporary Partial Benefits (e) Form DFS-F2-DWC-4 8/04 Notice of Action/Change (f) Form DFS-F2-DWC-12 8/04 Notice of Denial (g) Form DFS-F2-DWC-13 8/04 Claim Cost Report (h) Form DFS-F2-DWC-14 8/04 Request for Social Security Disability Benefit Information (i) Form DFS-F2-DWC-19 8/04 Employee Earnings Report (j) Form DFS-F2-DWC-30 8/04 Authorization and Request for Unemployment Compensation Information (k) Form DFS-F2-DWC-33 8/04 Permanent Total Offset Worksheet (l) Form DFS-F2-DWC-35 8/04 Permanent Total Supplemental Worksheet (m) Form DFS-F2-DWC-40 8/04 Statement of Quarterly Earnings for Supplemental Income Benefits (n) Form DFS-F2-DWC-49 8/04 Aggregate Claims Administration Change Report (o) Form DFS-F2-DWC-60 8/04 Important Workers' Compensation Information for Florida's Workers (p) Form DFS-F2-DWC-61 8/04 Informacion Importante De Seguro De Indemnizacion Por Accidentes De Trabajo Para Los Trabajadores De La Florida (q) Form DFS-F2-DWC-65 8/04 Important Workers' Compensation Information for Florida's Employers (r) Form DFS-F2-DWC-66 8/04 Informacion Importante Del Seguro De Indemnizacion Por Accidentes De Trabajo Para Los Empleadores De La Florida

(2) The Division will not supply the forms promulgated under this chapter, but will make sample forms available on the Division's web site: http://www.fldfs.com/wc.

(3) For a transitional period of 90 days from the effective date of this rule, an insurer or claims-handling entity may use forms identified and adopted in subsection 69L- 3.025(1), F.A.C., or the corresponding form(s) in effect prior to the adoption of this rule. After the completion of the 90 day transitional period, only the forms adopted in this rule may be used.

Specific Authority 440.15, 440.185, 440.20, 440.345 FS. Law Implemented 440.14(3), 440.15(1), (4), (9), (10), 440.185(4), (5), (10), 440.20(2), (3), 440.345, 440.35, 440.51(6), (9) FS. History-New 4-11-90, Amended 1-30-91, 11-8-94, 11-11-96, 11-25-96, Formerly 38F-3.025, 4L-3.025, Amended 1-10-05.