CLAIM COST REPORT FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION 200 East Gaines Street Tallahassee, FL 32399-4226 COMPLETE ALL APPLICABLE SECTIONS BEFORE FILING WITH THE DIVISION PLEASE PRINT OR TYPE SOCIAL SECURITY # EMPLOYEE NAME: (First, Middle, Last) SENT TO DIVISION DATE DIVISION RECEIVED DATE DATE OF ACCIDENT: (Month-Day-Year) TYPE OF REPORT INITIAL REPORT SUMMARIZING FIRST SIX MONTHS ANNUAL REPORT ON OPEN CASE FINAL REPORT- CASE CLOSED; NO ACTIVITY IN PAST YEAR OR CASE SETTLED AVERAGE WEEKLY WAGE (Do not Round) COMPENSATION RATE (Do not Round) FULL SALARY IN LIEU OF COMPENSATION FOR ANY PERIOD OF TIME? TYPE OF PAYMENT TEMPORARY PARTIAL WEEKS DAYS YES PAID TO DATE COLUMN I (Do not round) FULL SALARY END DATE _____ - _____ - _____ TYPE OF PAYMENT MEDICAL ALL DWC-9 & 11 HOSPITAL ALL DWC-90 TRANSPORTATION MEDICAL APPTS. DRUGS/SUPPLIES ALL DWC-10 HOME ATTENDANT CARE SKILLED NURSING CARE MISCELLANEOUS MEDICAL REHABILITATION ALL DWC-21 MEDICAL SETTLEMENT AMT. Date Payment Mailed: _____ - _____ - _____ PAID TO DATE COLUMN II (Do not round) TEMPORARY TOTAL TEMPORARY TOTAL ­ 80% TEMPORARY TOTAL- TRAINING & EDUCATION IMPAIRMENT INCOME BENEFITS STATUTORY PERMANENT IMPAIRMENT (D/A's prior to 01/01/94) WAGE LOSS (D/A"s prior to 01/01/94) SUPPLEMENTAL INCOME BENEFITS PERMANENT TOTAL Date accepted/adjud.: ______ - ______ - ______ PERMANENT TOTAL SUPPLEMENTAL TOTAL (PAID-TO-DATE COLUMNS I & II) DEATH FUNERAL (Amounts entered in paid-to-date columns I & II should not be reduced for recoveries except overpayment recoveries.) THIRD PARTY RECOVERY AMOUNT: _________ SPECIAL DISABILITY TRUST FUND RECOVERY AMOUNT: ALL OTHER RECOVERIES EXCEPT OVERPAYMENTS: _________ _________ COMPENSATION SETTLEMENT AMOUNT Date Payment Mailed: _____ - _____ - _____ PENALTIES (Paid to Claimant) INTEREST (Paid to Claimant) INSURER CODE # DATE PREPARED: (Month-Day-Year) INSURER NAME 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-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-13 (03/2009) Rule 69L-3.025, F.A.C. American LegalNet, Inc. www.FormsWorkflow.com DWC-13 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