CLAIMS-HANDLING ENTITY RECEIVED DATE STATEMENT OF QUARTERLY EARNINGS SENT TO DIVISION DATE DIVISION RECEIVED DATE FOR SUPPLEMENTAL INCOME BENEFITS DATES OF ACCIDENT ON OR AFTER JANUARY 1, 1984 THROUGH SEPTEMBER 30, 2003 FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION 1-800-342-1741 or contact your local office for assistance PLEASE PRINT OR TYPE SOCIAL SECURITY NUMBER EMPLOYEE NAME (First, Middle, Last) ACCIDENT EMPLOYER NAME A FILING PERIOD: DATE OF ACCIDENT:Month-Day-Year) ___________________________________ THROUGH ___________________________________ BEGINNING DATE ENDING DATE B NOTICE TO EMPLOYEE: Report all wages earned during the filing period in the area provided below. PLEASE CHECK APPROPRIATE BOXES: *** See instructions on the back side of this form *** I RETURNED TO WORK BUT MY REDUCED WAGES WERE A DIRECT RESULT OF MY IMPAIRMENT FROM THIS INJURY. DURING ANY WEEKS I WAS NOT EMPLOYED, I HAVE IN GOOD FAITH ATTEMPTED TO OBTAIN EMPLOYMENT, WHICH I AM ABLE TO DO. 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. I HAVE REVIEWED, UNDERSTAND, AND ACKNOWLEDGE THAT THE INFORMATION PROVIDED ON THIS FORM AND ANY ATTACHMENTS IS TRUE AND CORRECT. EMPLOYEE SIGNATURE: _____________________________________________________________________________________________ DATE: _________________________________ C CURRENT RATE OF PAY: $_______________PER HOURS PER DAY ____________ WEEK WEEK NO. FROM 1 HR WK DAY MO HOURS PER WEEK__________ DAYS PER WEEK __________ # OF DAYS # OF HOURS WORKED WORKED GROSS TO THAT WEEK THAT WEEK PAY GRATUITIES AS (CLAIMS- REPORTED TO THE EMPLOYER HANDLING ENTITY USE ONLY) DEEMED WAGES IN WRITING AS TAXABLE INCOME FRINGE BENEFITS (employee rec'd) EMPLOYER COST ONLY HEALTH INSURANCE RENT/ HOUSING 2 3 4 5 6 7 8 9 10 11 12 13 D MONTHLY SUPP. BENEFITS CALCULATION Pre-injury AWW x 4.3 x 0.80 = Adjusted Monthly Wage $ Minus (Current AWW x 4.3) = AREA BELOW FOR CLAIMS-HANDLING ENTITY USE ONLY 1 2 3 TOTALS: BENEFIT ADJUSTMENT DUE TO OVERPAYMENT Amount Paid for ____/____/____ thru ____/____/____ 4 5 $ TOTAL OF Current Monthly Wage 1+2+3+4+5 $ Paid on ______/______/______ Wage Loss $ Amount Due for ____/____/____ thru ____/____/____ Multiplied by 0.80 = Monthly S.I.B. Payable $ Total Amount of Overpayment Credit Equals Total Monthly $ $ DIVIDE BY # OF WEEKS IN $ EQUALS FILING PERIOD Payment Period Amount of Overpayment Credit applied per month ________/________/________ thru ________/________/________ (Not to EXCEED 20% of Monthly Payment) Subject to Maximum Payable Monthly Adjusted Amount due for at Comp Rate __________ x 4.3 $ Payment Amount for Initial Month ______/______/______ thru ______/______/______ CURRENT $ $ AVERAGE WEEKLY $ WAGE Remaining Overpayment Credit $ $ ADJUSTER NAME: Payment for filing period denied. See attached Notice of Denial. INSURER CODE # DATE PREPARED SERVICE CO/TPA CODE # CLAIMS-HANDLING ENTITY FILE # Form DFS-F2-DWC-40 (03/2009) RETURN THIS FORM TO: CLAIMS-HANDLING ENTITY NAME, ADDRESS AND TELEPHONE# Rule 69L-3.025, F.A.C. American LegalNet, Inc. www.FormsWorkflow.com STATEMENT OF QUARTERLY EARNINGS FOR SUPPLEMENTAL INCOME BENEFITS SOCIAL SECURITY NUMBER EMPLOYEE NAME (First, Middle, Last) DATE OF ACCIDENT: Month-Day-Year) INSTRUCTIONS: (1) Fill out Sections B and C on the front of this form. Use the form that has the first two lines on the front of the form with your name, etc. already completed. List any money you earned during the 13 weeks for the filing period shown on the second line. (2) Attach copies of paycheck stubs, statements from your employer(s), or any other documentation you may have of your earnings during the filing period. (3) If you have no earnings in a particular week, put down $0 for that week. (4) In the boxes below, list all employers you may worked for during the filing period, and the addresses, phone numbers and dates you were employed. (5) Sign and send the completed form to the Insurer or Claims-handling entity name and address noted in the lower right-hand corner on the front of this form. (6) Section 440.15(2), Florida Statutes, requires you to return this form in a timely manner and the failure to return this form may result in a delay in the payment of benefits. A Form DFS-F2-DWC-40, Statement of Quarterly Earnings for Supplemental Income Benefits, must be submitted at the end of every three months in order to receive these benefits. NAME OF EMPLOYER(S) DURING THIS FILING PERIOD Employer Name Employer Address Employer Phone Date(s) Employed Form DFS-F2-DWC-40 (03/2009) Rule 69L-3.025, F.A.C. American LegalNet, Inc. www.FormsWorkflow.com DWC-40 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