WAGE STATEMENT RECEIVED BY CLAIMS-HANDLING ENITY FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION NOTICE TO EMPLOYEE: If you have any questions about the information contained on this form, please contact your employer or claim-handling entity. If further assistance is needed, contact the Division's Employee Assistance Office at 1-800342-1741. PLEASE PRINT OR TYPE EMPLOYEE NAME (First, Middle, Last) CONCURRENT EMPLOYER NAME & ADDRESS (If applicable) EMPLOYER NAME & ADDRESS DATE OF ACCIDENT (Month-Day-Year) ARE THE WAGES LISTED BELOW FOR A SIMILAR EMPLOYEE? ___________ YES ___________ NO SIMILAR EMPLOYEE'S NAME TELEPHONE TELEPHONE OCCUPATION OF SIMILAR EMPLOYEE EMPLOYEE'S CUSTOMARY WORK WEEK EMPLOYEE'S CUSTOMARY DAYS WORKED/WEEK EMPLOYEE'S CUSTOMARY HOURS WORKED/WEEK _________________________________________ ____________________________________ _ __________________________________ (ex. Saturday thru Friday - Use 7 calendar day period) EMPLOYER'S CUSTOMARY WORK WEEK (ex. 40 hours / week) ______________________________________ (ex. Saturday thru Friday - Use 7 calendar day period) (ex. 5 days / week) NOTICE TO EMPLOYER: Please read all instructions on the back of this form carefully. Complete the form as fully as possible and submit it to your claims-handling entity within 14 days after knowledge of any accident that has caused your employee to be disabled for more than 7 calendar days. If you discontinue providing any fringe benefits, you must file a corrected Wage Statement with your claims-handling entity within 7 days of such termination, reflecting the type and amount of fringe benefits that were paid, and the last date they were provided. Please list wages earned for the 13 calendar weeks (Sunday through Saturday) immediately preceding the accident. Do Not Report Any Wages Earned During The Week of the Accident – Use The 13 Calendar Weeks Immediately Preceding The Accident WEEK # OF DAYS # HOURS WEEK WORKED WORKED GROSS NO. FROM TO THAT WEEK THAT WEEK PAY FRINGE BENEFITS (employee rec'd) EMPLOYER COST ONLY GRATUITIES AS REPORTED TO THE EMPLOYER IN WRITING AS HEALTH INSURANCE TAXABLE INCOME RENT/ HOUSING 1 2 3 4 5 6 7 8 9 10 11 12 13 ** RETURN THIS FORM TO: (Claims-handling entity Name, Address & Telephone #) WILL EMPLOYER CONTINUE TO PROVIDE ABOVE BENEFITS? TOTAL _____YES_____NO _____YES_____NO TOTAL FRINGE BENEFITS $ TOTAL OF GROSS PAY, GRATUITIES AND FRINGES $ AWW COMP RATE (FOR CLAIMS-HANDLING ENTITY USE ONLY) 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. ___________________________________________________________________________ PREPARER'S NAME Form DFS-F2-DWC-1a (03/2009) Rule 69L-3.025, F.A.C. ______________________________________________ TELEPHONE # ______________________________________________ DATE American LegalNet, Inc. www.FormsWorkflow.com WAGE STATEMENT REPORTING INSTRUCTIONS General: Florida law requires disabled employees to be compensated at a certain percentage of their average weekly wage. If the injured employee worked during “substantially the whole of 13 calendar weeks” immediately preceding the accident, the employee’s average weekly wage is one-thirteenth of the total amount of wages earned during the 13 calendar weeks. The term “substantially the whole of 13 calendar weeks” means not less than 75% of the total customary full-time hours of employment during that period. NOTICE TO EMPLOYER: Please read all instructions on this form carefully. Complete the form as fully as possible and submit it to your claims-handling entity within 14 days after your knowledge of any accident that has caused your employee to be disabled for more than 7 calendar days. If you discontinue providing any fringe benefits, you must file a corrected Form DWC-1a (Wage Statement) with your claims-handling entity within 7 days of such termination, reflecting the type and amount of fringe benefits that were paid, and the last date they were provided. • DO NOT combine wages of two or more employees. • Calendar Week: means a seven-day period of time, which starts on Sunday and continues through Saturday. Week of Accident – DO NOT report any wages earned during the week of the accident. Use the 13 calendar weeks immediately preceding the week of the accident and start with the most recent full calendar week before the week of the accident. For example, if the accident occurred on a Wednesday, then week No. 1 should begin the preceding Sunday and end the preceding Saturday. Reporting Gross Pay: Complete all columns as applicable. Report the actual gross earnings of the injured employee for the consecutive 13 calendar week period immediately preceding the accident. The 13 calendar week period includes Saturdays, Sundays, holidays, and other non-working days. Remember to include all overtime and any bonuses paid during the 13 calendar week period. If the injured employee was not employed for you for approximately 68 days during that period, enter the wages of a similar employee in the same employment who was employed for approximately 68 days of the 13 calendar week period. DO NOT combine wages for two or more employees to yield wages for the 13 calendar weeks. The spaces immediately following week #13 are to be used for reporting the wages earned in a partial week when requested. Reporting Gratuities & Fringe Benefits: Gratuities reported should include only those gratuities reported to the employer in writing as taxable income received in the course of employment from others than the employer. The reportable value of a fringe benefit is the actual cost to the employer for the benefit furnished. The only fringe benefits that can be included for dates of accident occurring on or after 07/01/1990 are employer contributions for health insurance for the employee or the employee’s dependents, and the reasonable value of housing furnished to the employee by the employer which is intended as the permanent year-round housing of the employee. If you have questions or need assistance in the completion of this required form, please contact the claims-handling entity listed on the front of this form. Form DFS-F2-DWC-1a (03/2009) Rule 69L-3.025, F.A.C. American LegalNet, Inc. www.FormsWorkflow.com