FIRST REPORT OF INJURY OR ILLNESS FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION For assistance call 1-800-342-1741 or contact your local EAO Office RECEIVED BY CLAIMS-HANDLING ENTITY SENT TO DIVISION DATE DIVISION RECEIVED DATE PLEASE PRINT OR TYPE NAME (First, Middle, Last) EMPLOYEE INFORMATION Social Security Number Date of Accident (Month-Day-Year) Time of Accident AM PM HOME ADDRESS Street/Apt #: _________________________________________________________ City: _________________________ State: _______________ Zip: ______________ TELEPHONE Area Code Number EMPLOYEE'S DESCRIPTION OF ACCIDENT (Include Cause of Injury) OCCUPATION INJURY/ILLNESS THAT OCCURRED PART OF BODY AFFECTED DATE OF BIRTH _________ / _________ / _________ SEX M F EMPLOYER INFORMATION FEDERAL I.D. NUMBER (FEIN) DATE FIRST REPORTED (Month/Day/Year) COMPANY NAME: ___________________________________________________ D. B. A.: ____________________________________________________________ NATURE OF BUSINESS Street: _____________________________________________________________ City: _________________________ State: _______________ Zip: ______________ TELEPHONE Area Code Number DATE EMPLOYED _________ / _________ / _________ LAST DATE EMPLOYEE WORKED EMPLOYER'S LOCATION ADDRESS (If different) _________ / _________ / _________ Street: _____________________________________________________________ City: ________________________ State: _______________ Zip: ______________ LOCATION # (If applicable) ____________________________________________ RETURNED TO WORK IF YES, GIVE DATE YES NO LAST DAY WAGES WILL BE PAID INSTEAD OF WORKERS' COMP _________ / _________ / _________ RATE OF PAY $ _________________ PER DAY AGREE WITH DESCRIPTION OF ACCIDENT? City: _________________________ State: _______________ Zip: ______________ COUNTY OF ACCIDENT ______________________________________________ YES NO Number of hours per day Number of hours per week Number of days per week 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 statement. __________________________________________________________________ EMPLOYEE SIGNATURE (If available to sign) __________________________________________________________________ EMPLOYER SIGNATURE _______________________________________________ DATE _______________________________________________ DATE CLAIMS-HANDLING ENTITY INFORMATION ______________________ ______________________ ______________________ MO HR WK PAID FOR DATE OF INJURY YES NO POLICY/MEMBER NUMBER WILL YOU CONTINUE TO PAY WAGES INSTEAD OF WORKERS' COMP? YES _________ / _________ / _________ DATE OF DEATH (If applicable) PLACE OF ACCIDENT (Street, City, State, Zip) _________ / _________ / _________ Street: _____________________________________________________________ NAME, ADDRESS AND TELEPHONE OF PHYSICIAN OR HOSPITAL AUTHORIZED BY EMPLOYER YES NO 1(a) Denied Case - DWC-12, Notice of Denial Attached 1(b) Indemnity Only Denied Case - DWC-12, Notice of Denial Attached 2. Medical Only which became Lost Time Case (Complete all required information in #3) Employee's 8TH Day of Disability _________ / _________ / _________ Entity's Knowledge of 8TH Day of Disability _________ /_________ / _________ 3. Lost Time Case - 1st day of disability _________ / _________ / _________ Date First Payment Mailed _________ / _________ / _________ Full Salary in lieu of comp? YES Full Salary End Date ________/ ________ / ________ Comp Rate ____________________________ AWW ____________________________ T.T. T.T. - 80% T.P. I.B. P.T. DEATH SETTLEMENT ONLY Penalty Amount Paid in 1st Payment $___________ REMARKS: Interest Amount Paid in 1st Payment $__________ INSURER NAME CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE INSURER CODE # EMPLOYEE'S CLASS CODE EMPLOYER'S NAICS CODE SERVICE CO/TPA CODE # CLAIMS-HANDLING ENTITY FILE # Form DFS-F2-DWC-1 (10/2016) Rule 69L-3.025, F.A.C. American LegalNet, Inc. www.FormsWorkFlow.com DWC-1 Purpose and Use Statement The collection of the social security number on this form is specifically authorized by Section 440.185(2), Florida Statutes. 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