CLAIMS-HANDLING ENTITY RECEIVED DATE EMPLOYEE EARNINGS REPORT SENT TO DIVISION DATE DIVISION RECEIVED DATE FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS’ COMPENSATION CAUTION FAILURE OR REFUSAL OF EMPLOYEE TO COMPLETE, SIGN, AND RETURN THIS REPORT WITHIN 21 DAYS AFTER THE DATE OF RECEIPT OF THE REQUEST MAY CAUSE PAYMENT OF BENEFITS TO STOP UNTIL SUCH TIME AS THE COMPLETED FORM IS FURNISHED TO THE REQUESTING PARTY. PLEASE PRINT OR TYPE I. IDENTIFICATION OF PARTIES (To be completed by requesting party) EMPLOYEE'S NAME (First, Middle, Last) EMPLOYEE'S SOCIAL SECURITY NUMBER DATE OF ACCIDENT: (Month-Day-Year) ACCIDENT EMPLOYER'S NAME & ADDRESS EMPLOYEE'S ADDRESS CLAIMS-HANDLING ENTITY NAME & ADDRESS II. NOTICE TO EMPLOYEE THE WORKERS' COMPENSATION LAW REQUIRES ALL PERSONS RECEIVING OR CLAIMING BENEFITS FOR TEMPORARY DISABILITY AND/OR PERMANENT TOTAL DISABILITY TO REPORT ALL EARNINGS OF ANY NATURE TO THE EMPLOYER, INSURANCE COMPANY AND/OR DIVISION OF WORKERS' COMPENSATION. PLEASE COMPLETE THIS REPORT AND RETURN IT TO THE REQUESTING PARTY WITHIN 21 DAYS AFTER THE DATE OF YOUR RECEIPT. TIME PERIOD TO BE REPORTED HAVE YOU RECEIVED INCOME FROM ANY SOURCE OTHER THAN WORKERS' COMPENSATION? FROM TO (IF YES, COMPLETE FORM, SIGN, DATE, & RETURN) YES (IF NO, SIGN, DATE AND RETURN) NO IF NECESSARY, ATTACH ADDITIONAL EARNINGS DOCUMENTATION (IF YES, COMPLETE INFORMATION BELOW) III. HAVE YOU RECEIVED EARNINGS FROM ANY PERSON, FIRM OR COMPANY YES DURING THE TIME PERIOD IN SECTION II? NO PERSON/FIRM/COMPANY NAME YES NO DATES SELF-EMPLOYED TO TOTAL GROSS EARNINGS BRIEFLY DESCRIBE NATURE OF BUSINESS OR SERVICE IV. DURING THE TIME PERIOD IN SECTION II, HAVE YOU BEEN SELF-EMPLOYED? FROM PERIOD WORKED FROM TO ADDRESS DATES SELF-EMPLOYED WAGES, INCOME OR BENEFITS RECEIVED FROM V. DURING THE TIME PERIOD IN SECTION II, HAVE YOU RECEIVED ANY SOCIAL SECURITY BENEFITS? TOTAL MONTHLY SOCIAL SECURITY INCOME AMOUNT PAID FOR YOUR DISABILITY FROM WAGES, INCOME OR BENEFITS RECEIVED YES VI. DURING THE TIME PERIOD IN SECTION II, HAVE YOU RECEIVED WAGES, INCOME, OR BENEFITS FROM ANY OTHER SOURCE, i.e. Unemployment Compensation Benefits, Workers' Compensation Benefits from another insurer, etc? Attach additional documentation if necessary. SOURCE OF WAGES, INCOME OR BENEFITS TO PERIOD BENEFITS RECEIVED TO (IF YES, STATE AMOUNTS) NO AMOUNT PAID FOR YOUR DEPENDENTS YES (IF YES, STATE AMOUNTS) NO TOTAL AMOUNT 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. I HAVE REVIEWED, UNDERSTAND, AND ACKNOWLEDGE THE ABOVE. THIS INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. EMPLOYEE'S SIGNATURE _____________________________________________________________________ DATE ____________________________________________________ VII. RETURN TO (To be completed by requesting party): REQUESTING PARTY'S NAME REQUESTING PARTY'S SIGNATURE TITLE DATE: (Month-Day-Year) REQUESTING PARTY'S ADDRESS & TELEPHONE Form DFS-F2-DWC-19 (03/2009) Rule 69L-3.025, F.A.C. American LegalNet, Inc. www.FormsWorkflow.com DWC-19 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