Response To Petition For Benefits
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Response To Petition For Benefits Form. This is a Florida form and can be use in Workers Comp.
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Tags: Response To Petition For Benefits, Florida Workers Comp,
STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
OFFICE OF THE JUDGES OF COMPENSATION CLAIMS
Employee/Claimant,
v.
Employer,
and
Carrier/Servicing Agent.
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OJCC Case No.:
Assigned Judge:
Accident Date:
RESPONSE TO PETITION FOR BENEFITS
LOST TIME CASE: (Y/N)
MEDICAL BENEFITS CASE: (Y/N)
RESPONSE TO EACH BENEFIT REQUESTED:
(If Denial of Benefit(s) was rescinded, include the initial indemnity start date, disability type, average weekly wage and compensation
rate.)
DENIAL OF BENEFIT WAS RESCINDED ON:
CARRIER:
CARRIER’S CODE:
ADDRESS:
CARRIER’S FILE NO.:
TELEPHONE:
DATE PREPARED:
ADJUSTER:
COPY FURNISHED:
TELEPHONE:
ADDRESS:
NOTICE: If you do not agree with the employer/carrier's action or you do not understand why you received this information, please
contact your adjuster. For further assistance, please contact the Employee Assistance and Ombudsman Office at (800) 342-1741.
OJCC Form RPFB (Revised 3-1-2007)
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