REIMBURSEMENT REQUEST FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION OFFICE OF SPECIAL DISABILITY TRUST FUND 200 East Gaines Street Tallahassee, Florida 32399-4223 SDTF RECEIVED DATE Note: This report must be signed by the employer or his duly authorized agent or carrier. Supporting records are subject to audit by the Division of Workers' Compensation. The signed original and one copy must be filed with the Fund by the employer or carrier requesting reimbursement. PLEASE PRINT OR TYPE EMPLOYEE NAME SDTF CLAIM NUMBER DATE OF ACCIDENT NAME OF EMPLOYER CARRIER CODE # SERVICE CO/TPA CODE # BASE COMPENSATION RATE COMPENSATION RATE COMPENSATION RATE WITH S/S OFFSET $ IMPAIRMENT RATING % MMI DATE PT DATE PERMANENT IMPAIRMENT (D/A Before 1/1/94) PI DATE IMPAIRMENT INCOME (D/A On or After 1/1/94) From WAGE LOSS To TEMPORARY TOTAL From TEMPORARY PARTIAL From MEDICAL (PHYSICIAN FEES) From HOSPITAL To To From To SUPPLEMENTAL INCOME BENEFITS (D/A On or After 1/1/94) From PERMANENT TOTAL To To From To PERMANENT TOTAL SUPPLEMENTAL From To LUMP SUM SETTLEMENT (JPO) Date DEATH From To TOTAL PERMANENT COMPENSATION From To DRUGS, BRACES, PROSTHESIS, OTHER SUPPLIES From To TRAVEL / MILEAGE From ATTENDANT CARE From FUTURE MEDS To To TOTAL MEDICAL AND TEMPORARY COMPENSATION PERIOD FOR WHICH REIMBURSEMENT IS REQUESTED From To TOTAL REIMBURSED PRIOR TO THIS REQUEST $ THIRD PARTY RECOVERIES $ NAME AND ADDRESS OF PAYEE: TOTAL PERMANENT, TEMPORARY AND MEDICAL BENEFITS TOTAL AMOUNT REIMBURSEMENT REQUESTED $ CALCULATIONS/FORMULA PAYEE'S FEDERAL TAX ID# ______________________________________ MAIL CHECK TO: COMMENTS ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY EMPLOYER OR EMPLOYEE, INSURANCE COMPANY, SELF-INSURED PROGRAM, FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE OR MISLEADING INFORMATION IS GUILTY OF A FELONY IN THE THIRD DEGREE. I HEREBY CERTIFY THAT ALL OF THE SUMS LISTED ON THIS FORM HAVE BEEN PAID, AND I FURTHER CERTIFY THAT EXPENDITURES FOR ATTORNEYS FEES, PENALTIES AND INTEREST, DEPOSITION AND COURT COSTS HAVE NOT BEEN INCLUDED ON THIS PREPARER'S SIGNATURE: SIGNED BY: CARRIER NAME, ADDRESS & TELEPHONE # PREPARER'S TYPED NAME: TITLE: PREPARER'S TELEPHONE #: DATE: FORM DFS-F1-SDF-2 (Rev. 3/09) Rule 69L-10.019, F.A.C. American LegalNet, Inc. www.FormsWorkFlow.com ATTACH APPROPRIATE DOCUMENTATION 1. TT - DWC-4 2. TP - DWC-3 3. WAGE LOSS - DWC-3's 4. PTD PAYSHEET 5. DEATH PAYSHEET 6. PI - DRAFT COPIES AND DWC-4's NOTE: DWC-3's AND DWC-4's MUST BE FULLY COMPLETED WITH SIGNATURE, DATE PAID AND AMOUNT PAID. EMPLOYEE'S NAME INSTRUCTIONS: CLAIM NUMBER DATE OF ACCIDENT PERIOD COMPENSATION RATE TEMPORARY TOTAL TEMPORARY PARTIAL WAGE LOSS PERMANENT TOTAL DEATH BENEFITS PERMANENT IMPAIRMENT TOTALS Page _______________ of _______________ PAYMENT SCHEDULE A American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS: 1. COMPLETE THIS FORM. 2. TOTAL AND ATTACH BILLS IN DATE OF SERVICE ORDER. 3. ATTACH AUDIT TAPE. EMPLOYEE'S NAME CLAIM NUMBER DATE OF ACCIDENT MEDICALS NAME OF PROVIDER DATE OF SERVICE DATE PAID AMOUNT PAID TOTALS Page _______________ of _______________ PAYMENT SCHEDULE B American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS: 1. COMPLETE THIS FORM. 2. TOTAL AND ATTACH BILLS IN DATE OF SERVICE ORDER. 3. ATTACH AUDIT TAPE. EMPLOYEE'S NAME CLAIM NUMBER DATE OF ACCIDENT HOSPITAL NAME OF PROVIDER DATE OF SERVICE DATE PAID AMOUNT PAID TOTALS Page _______________ of _______________ PAYMENT SCHEDULE C American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS: 1. COMPLETE THIS FORM. 2. TOTAL AND ATTACH BILLS IN DATE OF SERVICE ORDER. 3. ATTACH AUDIT TAPE. EMPLOYEE'S NAME CLAIM NUMBER DATE OF ACCIDENT RX AND MILEAGE NAME OF PROVIDER DATE OF SERVICE DATE PAID AMOUNT PAID TOTALS Page _______________ of _______________ PAYMENT SCHEDULE D American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS: 1. COMPLETE THIS FORM. 2. TOTAL AND ATTACH BILLS IN DATE OF SERVICE ORDER. 3. ATTACH AUDIT TAPE. EMPLOYEE'S NAME CLAIM NUMBER DATE OF ACCIDENT MISCELLANEOUS (PLEASE SPECIFY) NAME OF PROVIDER DATE OF SERVICE DATE PAID AMOUNT PAID TOTALS Page _______________ of _______________ PAYMENT SCHEDULE E American LegalNet, Inc. www.FormsWorkFlow.com