Florida Regulations 69L-3.025 44

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§ Forms

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

First Report of Injury or Illness LES Form DWC- 1 Effective 11-8-94

For use only by those approved to transmit electronic First ACORD 4 or Effective 11-8-94

Reports of Injury to the Division LES Form IA-1

Wage Statement LES Form DWC- 1a Effective 11-11-96

Request for Wage Loss/ Temporary Partial Benefits LES Form DWC-3 Effective 1-30-9 1

Notice of Action/Change LES Form DWC-4 Effective 11-8-94

Notice of Denial LES Form DWC-12 Effective 11-8-94

Claim Cost Report LES Form DWC-13 Effective 11-8-94

Request for Social Security Disability Benefit information LES Form DWC- 14 Effective 11-8-94

Employee Earnings Report LES Form DWC- 19 Effective 11-8-94

Authorization and Request for Unemployment Compensation Information LES Form DWC-30 Effective 11-8-94

Statement of Quarterly Earnings for Supplemental Income Benefits LES Form DWC-40 Effective 11-8-94

Monthly Risk Class/SIC Code Report LES Form DWC-48 Effective 11-8-94

Aggregate Claims Administration Change Report LES Form DWC-49 Effective 11-8-94

Aggregate Defense Attorney LES Form DWC-51 Effective 11-25-96

Fee Report

(2) An individual or entity requiring any form promulgated under this rule can obtain the form(s) from printers throughout the state. The Division will not supply the forms promulgated under this chapter, but can provide sample copies.

Specific Authority 440.15,440.185, 440.20, 440.345, F.S. Law lmplemented 440.15, 440.185, 440.20, 440.345, F.S. History New 4-11-90, Amended 1-30-91, 11-8-94, 11-11-96,11-25-96.