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Florida Administrative Code (Last Updated: April 18, 2024) |
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69. Department of Financial Services |
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69L. Division of Workers' Compensation |
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69L-3. Workers' Compensation Claims |
1(1) The following forms are to be used with this rule chapter and are hereby incorporated by reference:
19(a)
20Form DFS-F2-DWC-1
223/16/09
23First Report of Injury or Illness
29(b)
30Form IA-1
321/1/02
33Workers’ Compensation ‒ First Report of Injur40y or Illness, © International Association of Industrial Accident Boards and Commissions (IAIABC) 2002. Note: Form IA-1 is to be used only by those entities approved to transmit electronic First Reports of Injury to the Division
76(c)
77Form DFS-F2-DWC-1a
793/16/09
80Wage Statement
82(d)
83Form DFS-F2-DWC-4
853/16/09
86Notice of Action/Change
89(e)
90Form DFS-F2-DWC-12
923/16/09
93Notice of Denial
96(f)
97Form DFS-F2-DWC-13
993/16/09
100Claim Cost Report
103(g)
104Form DFS-F2-DWC-14
1063/16/09
107Request for Social Security Disability Benefit Information
114(h)
115Form DFS-F2-DWC-19
1173/16/09
118Employee Earnings Report
121(i)
122Form DFS-F2-DWC-30
1243/16/09
125Authorization and Request for Unemployment Compensation Information
132(j)
133Form DFS-F2-DWC-33
1353/16/09
136Permanent Total Offset Worksheet
140(k)
141Form DFS-F2-DWC-35
1433/16/09
144Permanent Total Supplemental Worksheet
148(l)
149Form DFS-F2-DWC-40
1513/16/09
152Statement of Quarterly Earnings for Supplemental Income Benefits
160(m)
161Form DFS-F2-DWC-60
16303/10
164Important Workers’ Compensation Information for Florida’s Workers
171(n)
172Form DFS-F2-DWC-61
17402/14
175Informacion Importante De Seguro De Indemnizacion Por Accidentes De Trabajo Para Los Trabajadores De La Florida 191http://www.flrules.org/Gateway/reference.asp?No=Ref-04179
193(o)
194Form DFS-F2-DWC-65
19603/10
197Important Workers’ Compensation Information for Florida’s Employers
204(p)
205Form DFS-F2-DWC-66
20703/10
208Informacion Importante Del Seguro De Indemnizacion Por Accidentes De Trabajo Para Los Empleadores De La Florida
224(2) The Division will not supply the forms promulgated under this chapter, but will make sample forms available on the Division’s web site: 247http://www.myfloridacfo.com/division/WC/.
248Rulemaking Authority 250440.15, 251440.185, 252440.20, 253440.591 FS. 255Law Implemented 257440.02, 258440.05, 259440.102, 260440.107, 261440.12, 262440.13, 263440.14, 264440.15, 265440.16, 266440.185, 267440.19, 268440.191, 269440.192, 270440.20(2), 271(3), 272440.21, 273440.34(3), 274440.345, 275440.35, 276440.40, 277440.491, 278440.51(6), 279(9) 280FS. History–New 4-11-90, Amended 1-30-91, 11-8-94, 11-11-96, 11-25-96, Formerly 38F-3.025, 4L-3.025, Amended 1-10-05, 3-16-09, 11-30-10, 6-30-14.
