REQUEST FOR ASSISTANCE EMPLOYEE ASSISTANCE OFFICE DO NOT WRITE IN THIS AREA DATE STAMP DIVISION OF WORKERS’ COMPENSATION STATE OF FLORIDA PLEASE PRINT THE FOLLOWING INFORMATION: NAME: SEQ#: OFFICE ASSIGNED TO: EMPLOYEE TELEPHONE #: (OR CONTACT NUMBER) EMPLOYEE STREET ADDRESS: DATE/ACCIDENT: WORKERS’ COMP. INSURANCE COMPANY: INSURANCE CO. TELEPHONE: ( CITY: TIME/ACC: ST: ZIP CODE: ) INSURANCE CO. ADDRESS: COUNTY OF EMPLOYEE RESIDENCE: EMPLOYER’S NAME (COMPANY) & ADDRESS: CITY: ST: ZIP CODE: CLAIM REPRESENTATIVE’S (ADJUSTER) NAME: EMPLOYER’S TELEPHONE #: ( ) THE INFORMATION YOU SUPPLY WILL BE USED TO PROCESS YOUR REQUEST. THE MORE COMPLETE AND SPECIFIC THE INFORMATION THE BETTER WE WILL BE ABLE TO SERVE YOU. This form is to be used to request help to resolve a dispute over benefits due and not received from your Employer/Carrier. YES NO ARE YOU REPRESENTED BY AN ATTORNEY? (CHECK BOX) ATTORNEY’S NAME/BAR NUMBER: ATTORNEY’S ADDRESS AND TELEPHONE #: WHO IS REQUESTING ASSISTANCE? (CHECK THE BOX THAT APPLIES): Employee Health Care Provider Employer Carrier/TPA Other (Describe Here): WHAT IS THE PROBLEM AREA? PLEASE CHECK THE BOX THAT APPLIES. ENTIRE CLAIM DENIED? CHECK LATE? OTHER? MEDICAL BILL NOT PAID? NEED A DOCTOR? IMPORTANT PLEASE USE THE SPACE ON THE BACK OF THIS FORM TO EXPLAIN, IN DETAIL, WHAT YOU NEED AND WHY THE FOLLOWING ACTIONS SHOULD BE NOT FILED WITH THE EAO OFFICE: **CLAIMS FOR S.D.T.F. **ALL MOTIONS TO J.C.C. **REQUESTS FOR ATTORNEY’S FEES AND COSTS EAO1 **CLAIMS FOR CONTRIBUTION **AMENDED PETITIONS REV:4/21/08 American LegalNet, Inc. www.FormsWorkflow.com NAME: DATE/ACCIDENT: TIME/ACC: PLEASE USE THE SPACE BELOW TO EXPLAIN IN DETAIL YOUR PROBLEM: FOR EXAMPLE: IF YOU FEEL YOU ARE OWED A CHECK, PUT THE DATE AND WHAT THE DOCTOR SAID YOUR WORK STATUS WAS AT THAT TIME. (NO WORK, LIGHT DUTY, AND EARNING LESS OR LOOKING FOR WORK, OR DOCTOR GAVE YOU PERMANENT RESTRICTIONS & YOU ARE LOOKING FOR WORK). IF THE PROBLEM IS ABOUT AN UNPAID MEDICAL BILL, HOW MUCH THE BILL IS, WHAT DOCTOR OR DRUGSTORE & THE DATES OF THE BILLS. PROBLEM DEFINED: ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ NOTE: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY EMPLOYER OR EMPLOYEE, INSURANCE CO. OR SELF-INSURED PROGRAM, FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. It is the duty of all who participate in the workers’ compensation process to attempt to resolve disagreements in good faith. Have you contacted the insurance carrier, or employer’s servicing company? YES NO Date Contacted: Reason for no contact: ________________________________________________ Adjuster/Representative’s Name: ________________________________________________ ________________________________________________ Adjuster/Representative’s telephone number: ________________________________________________ SIGNATURE OF REQUESTOR: ____________________________________________________________ DATE: ______________________________ NAME, TITLE, ADDRESS, & TELEPHONE # OF REQUESTOR – IF NOT EMPLOYEE: TELEPHONE: (______) __________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ WHEN YOU HAVE FULLY COMPLETED THIS FORM, PLEASE MAIL IT TO THIS ADDRESS, OR IF YOU NEED ASSISTANCE, PLEASE CALL AT 1 (800) 342-1741 EMPLOYEE ASSISTANCE OFFICE DIVISION OF WORKER’S COMPENSATION P.O. BOX 8010 TALLAHASSEE, FLORIDA 32314-8010 EAO1 REV:4/21/08 American LegalNet, Inc. www.FormsWorkflow.com