SENT TO DIVISION DATE NOTICE OF DENIAL DIVISION RECEIVED DATE FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS’ COMPENSATION 200 East Gaines Street Tallahassee, Florida 32399-4226 COMPLETE ALL APPLICABLE SECTIONS BEFORE FILING WITH THE DIVISION PLEASE PRINT OR TYPE SOCIAL SECURITY NUMBER EMPLOYEE NAME (First, Middle, Last) EMPLOYEE ADDRESS DATE OF ACCIDENT: (Month-Day-Year) EMPLOYER NAME ATTACH ADDITIONAL PAGE(S) IF NECESSARY DENIED BENEFITS (List below) REASON FOR DENIAL OF BENEFITS (Provide detailed information to support reason(s) for denial) DATE DENIAL RESCINDED: _____ / ____ / _______ Description of benefits reinstated or started: CC: (Name and Address) ADJUSTER TELEPHONE ADJUSTER NAME ( INSURER CODE DATE PREPARED SVC. CO/TPA CODE ) __________ - ________________ Ext. _______ INSURER NAME CLAIMS-HANDLING ENTITY FILE # CLAIMS-HANDLING ENTITY NAME AND ADDRESS 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-12 (03/2009) RULE 69L-3.025, F.A.C. American LegalNet, Inc. www.FormsWorkflow.com DWC-12 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