PERMANENT TOTAL SUPPLEMENTAL WORKSHEET DIVISION RECEIVED DATE SENT TO DIVISION DATE FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION 200 East Gaines Street Tallahassee, FL 32399-4224 PLEASE PRINT OR TYPE EMPLOYEE NAME, ADDRESS & TELEPHONE #: DATE OF ACCIDENT: (Month-Day-Year) SOCIAL SECURITY #: GUARDIAN, If applicable DATE OF BIRTH: CARRIER PAY PT ACCEPTANCE/ADJUDICATION DATE: _____________________________ (Month-Day-Year) DIVISION PAY COMMPUTATION OF SUPPLEMENTAL WEEKLY COMPENSATION AWW: $____________________________ STEP 1: A. B. x $____________________________ Enter employee’s compensation rate in accordance with the Law in effect on the date of accident. $____________________________ Amount of 5% supplemental authorized (3% for dates of accident on or after October 1, 2003) C. = $____________________________ Basic Weekly Increase D. x $ ___________________________ E. = $____________________________ Total weekly supplemental – Enter below in (A1) Number of CALENDAR years since the date of accident • STEP 2: A. Subtract year of accident from year of PT Acceptance/Adjudication $____________________________ (Enter the figure from STEP 1A) B. + $____________________________ (Enter the figure form STEP 1E) C. = $____________________________ (TOTAL – cannot exceed maximum for appropriate year) THE MAXIMUM WEEKLY COMPENSATION RATE: 1. $_______________ per week, beginning ____________________ 4. $_______________ per week, beginning ____________________ 2. $_______________ per week, beginning ____________________ 5. $_______________ per week, beginning ____________________ 3. $_______________ per week, beginning ____________________ 6. $_______________ per week, beginning ____________________ STEP 3: Weekly supplemental divided by; 7 x total number of days in year. Combine yearly amounts to get total initial payment due to claimant. (A1) Weekly Supplemental Rate Beginning Date (MM/DD/YY) First Regular Payment Amount (Weekly Amount x 4 = Division Pay) Ending Date (MM/DD/YY) (B1) Total Number of Days (C1) Total Amount (A1 divided by 7 x B1 = C1) Comments (if any) TOTAL INITIAL PAYMENT $___________________ $_______________________________ Payment Date ___________________ (Weekly Amount x 2 = Carrier Pay) 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. INSURER CODE ADJUSTER NAME: INSURER NAME: CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE SERVICE CO./TPA CODE # DATE PREPARED: (Month-Day-Year) Form DFS-F2-DWC-35 (03/2009) 69L-3.025, F.A.C. American LegalNet, Inc. www.FormsWorkflow.com DWC-35 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