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: _______ - _______ - ______ EFFECTIVE DATE REASON CODE: ______________________ _______ - _______ - ______ EFFECTIVE DATE INDEMNITY REINSTATED AFTER SUSPENSION: DISABILITY TYPE: ______________________ RELEASED TO RETURN TO WORK DATE: _________ - _________ - _________ RESTRICTIONS?: YES NO ACTUAL RETURN TO WORK DATE: _________ - _________ - _________ RESTRICTIONS?: YES NO DATE FINAL SETTLEMENT ORDER MAILED: _________ - _________ - _________ OVERALL MMI DATE: _________ - _________- _________ PI RATING: __________ % BAW DATE OF DEATH _________ - _________ - _________ PERMANENT IMPAIRMENT BENEFITS (D/A'S PRIOR TO 01/01/94): DATE PAID: _________ - _________ - _________ IMPAIRMENT INCOME BENEFITS (D/A'S ON OR AFTER 01/01/94): START DATE: _________ - _________ - _________ WEEKLY RATE: TOTAL NUMBER OF WEEKS OF ENTITLEMENT: PERMANENT TOTAL: DATE ACCEPTED/ADJUDICATED _________ - _________- _________ $ _______________________________ PREVIOUS COMP RATE: $ _______________________________ AMENDED AWW: $ _______________________________ __________ AMENDED COMP RATE: $ _______________________________ RETROACTIVE TO D/A: __________ IF NO, GIVE EFFECTIVE DATE: _________ - _________- _________ BENEFIT ADJUSTMENTS BENEFIT ADJUSTMENT CODE __________ YES DISABILITY TYPE ADJUSTED DISABILITY TYPE ADJUSTED __________ WEEKLY ADJ AMOUNT $ WEEKLY ADJ AMOUNT $ NO _________ - _________- _________ __________ __________ EFFECTIVE DATE EFFECTIVE DATE ADJUSTMENT END DATE AVERAGE WEEKLY WAGE AND/OR COMPENSATION RATE AMENDMENTS: PREVIOUS AWW: $ ______________________________ WEEKLY PT SUPP EFFECTIVE DATE __________ __________________ __________ WEEKLY PT SUPPLEMENTAL RATE BENEFIT ADJUSTMENT CODE $ _________________ __________ ADJUSTMENT END DATE __________ CORRECTIONS OF: CLASS CODE SOCIAL SECURITY NUMBER/CORRECT #: ________________________________________________ DATE OF ACCIDENT/CORRECT DATE: _______________ - _______________ - ______________ EMPLOYEE’S NAME/CORRECT NAME: ________________________________________________ CLAIMS-HANDLING ENTITY: ________________________________________________ NAICS CODE REMARKS: ______________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________ CC: INSURER NAME INSURER CODE # DATE PREPARED: (Month-Day-Year) SERVICE CO/TPA CODE # CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE CLAIMS-HANDLING ENTITY FILE # _________ - _________ - _________ 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-4 (03/2009) Rule 69L-3.025, F.A.C. American LegalNet, Inc. www.FormsWorkflow.com KEY FOR DFS-F2-DWC-4 TYPES / CODES DISABILITY TYPES: TT Temporary Total Disability Benefits TTC Temporary Total Disability Benefits at 80% for severe injuries per Section 440.15(2)(b), FS. TTE Temporary Total Benefits while in an approved training and education program TP Temporary Partial Disability Benefits PI Permanent Impairment Benefits (Dates of Accident from 08/01/79 through 12/31/93) IB Impairment Income Benefits (Dates of Accident on or after 01/01/94) WL Wage Loss Benefits (Dates of Accident from 08/01/79 through 12/31/93) SB Supplemental Benefits (Dates of Accident on or after 01/01/94) PT Permanent Total Disability Benefits DB Death Benefits SUSPENSION REASON CODES: (All Indemnity Benefits have been suspended because:) S1 The employee returned to work, or was medically released to return to work S2 The employee did not comply with medical treatment requirements in the Workers’ Compensation Law / Rules S3 The employee did not comply with administrative requirements in the Workers’ Compensation Law / Rules S4 The employee died S5 The employee became incarcerated in a public institution S6 The employee’s whereabouts are unknown S7 The employee’s benefits have been used up or entitlement to those benefits has ended S8 The employee’ claim has been changed to another jurisdiction BENEFIT ADJUSTMENT CODES: (The employee’s rate of pay is being reduced or adjusted because of:) A Apportionment / Contribution from another insurer B Subrogation / Third Party Recovery C Overpayment of Benefits from the insurer H Child Support Payment N Employee not complying with Medical or Training and Education requirements P Carrier taking credit for an advance given to the employee R Social Security Retirement Benefits received by the employee S Social Security Disability Benefits received by the employee U Unemployment Compensation Benefits received by the employee V A Safety Violation by the employee X A change in the dependents entitled to Death Benefits Form DFS-F2-DWC-4 (03/2009) Rule 69L-3.025, F.A.C. American LegalNet, Inc. www.FormsWorkflow.com 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. American LegalNet, Inc. www.FormsWorkflow.com