STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS OFFICE OF THE JUDGES OF COMPENSATION CLAIMS PETITION FOR WORKERS' COMPENSATION BENEFITS Employee/Claimant petitions the Office of the Judges of Compensation Claims for an order requiring Employer/Carrier to provide benefits due under Chapter 440, Florida Statutes as claimed below. EMPLOYEE: ADDRESS: TELEPHONE: EMPLOYER: ADDRESS: TELEPHONE: CLAIMANT'S NAME (if different from the employee): ADDRESS: EMPLOYEE/CLAIMANT'S ATTORNEY (if any): FLORIDA BAR NO.: ADDRESS: DATE OF ACCIDENT (disablement date if occupational disease): ACCIDENT COUNTY: ACCIDENT STATE: DETAILED DESCRIPTION OF JOB RESPONSIBILITIES: SPECIFIC WORK BEING PERFORMED WHEN INJURY OCCURRED: TELEPHONE NO.: OJCC CASE NO. (required if previously issued): or, EMPLOYEE'S SOCIAL SECURITY NO.: or attach a VERIFIED MOTION FOR SUBSTITUTE IDENTIFICATION NUMBER (form available on the OJCC website at www.jcc.state.fl.us) CARRIER: ADDRESS: TELEPHONE: TELEPHONE NO.: DETAILED DESCRIPTION OF THE ACCIDENT: IS THIS PETITION FOR MEDICAL BENEFITS ONLY (Y/N): AWW 13 WEEKS PRECEDING ACCIDENT: PART(S) OF BODY INJURED: CURRENT AWW: CURRENTLY WITH SAME EMPLOYER (Y/N): CURRENT WORK LEVEL: HAS MMI BEEN REACHED (Y/N): IF SO, DATE OF MMI: 1. Jurisdiction: The Judge of Compensation Claims has jurisdiction over the parties and the subject matter of this petition. 2. Managed care grievance procedures, if required, were exhausted under F.S. §440.192(3). The Grievance was dated: ________________. 3. Character of disability. The injury/injuries occasioned by the events described above has/have adversely affected the injured employee's capacity to earn in the same or any other employment the wages that the employee was receiving at the time of the injury. Specifically, the injury prevents the injured employee from: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ___________________________________________________________________________________________. OJCC Form PFB (Revised 4-4-2011) Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 4. The following benefits are claimed due, ripe and owing but not provided: _____ Temporary Total Disability benefits from ______/______/______ to ______/______/______ at a specific monetary compensation rate of $_______________ per week. _____ Temporary Partial Disability benefits from ______/______/______ to ______/______/______ at a specific monetary compensation rate of $_______________ per week. _____ For accidents prior to 1994, impairment benefits due under Section 440.15(3)(a), Florida Statutes, (1979) $_______________. The permanent impairment due to the injury is _______% of the whole body. These benefits are based on: ____ Permanent Impairment due to total loss of use of _________________(body part affected). ____ Permanent Impairment due to amputation of _____________________________________________, (which was amputated after July 1, 1990). ____ Permanent Impairment due to the loss of 80% vision of either eye after correction. ____ Serious facial injury or head disfigurement. _____ For accidents prior to 1994, Wage-loss benefits payable under Section 440.15(3)(b), Florida Statutes, from ______/______/______ to ______/______/______ at a rate of $_______________ per week. If the petitioner had earnings during the foregoing period of time, attach a list of the earnings on a biweekly basis or attach wage-loss request forms. _____ Impairment benefits of $______________ due under Section 440.15(3)(a)3, Florida Statutes (1994). _____ Supplemental benefits of $_____________ due under Section 440.15(3)(b), Florida Statutes (1994). _____ Permanent Total Disability benefits under Section 440.15(1), Florida Statutes, from ______/______/______ to the present and continuing at a rate of $_____________ per week. _____ Death benefits payable under Section 440.16, Florida Statutes. _____ Correction of AWW and resulting Compensation Rate due to ____________________________________ _____________________________________________________________________________________. _____ Medical Expenses incurred for treatment of the employee's injury as provided under Section 440.13(2), Florida Statutes. The employee has specifically requested the payment of the charges, but the employer/carrier has failed, refused, or neglected to do so within a reasonable amount of time. The following medical charges have not been paid (use additional paper if necessary): _____________________________________________________________________________________. _____ Medical care under the supervision of Dr(s): __________________________________________________ _____________________________________________________________________________________. The employee has previously requested the treatment, but the employer/carrier has failed, refused, or neglected to provide such treatment within a reasonable time. _____ The injured employee seeks _________________________________________ (type of medical treatment). _____ The treatment is needed because _________________________________________________________. _____ Medically necessary (professional/nonprofessional) attendant care as per the direction of a physician. The employee has previously specifically requested the attendant care, but the employer/carrier has failed, refused, or neglected to provide the care within a reasonable time. The injured employee seeks attendant care because ___________________________________________________________________________. Physician who prescribed care: Dr. _____________________________. _____ Reimbursement of mileage to and from medical care providers in the amount of $____________ (mileage statement must be attached). _____ Rehabilitative Temporary Total Compensation under Section 440.491(6)(b), Florida Statutes, from ______/______/______ to ______/______/______ at a specific rate of $____________ per week. _____ Interest and Penalties on unpaid benefits. _____ Costs and attorney's fees from E/C under Section 440.34(3)(a)-(d), Florida Statutes. _____ Reimbursement of prescription bills in the amount of $_____________ (see attached). _____ The employer/carrier/servicing agent has denied the compensability of the accident or injury. _____ Other issue(s) not referenced above: ______________