69L-6.007. Compensation Notice

(1)(a) Upon issuance of an insurance policy or certificate of membership in a self-insurance fund or a renewal certificate thereof, the insurer or self-insurance servicing agent shall electronically send the compensation notice to the employer or furnish the employer with a sufficient number of typewritten or printed compensation notices, commonly referred to as the “broken arm poster.” The compensation notice shall be printed on paper or cardboard stock 11 inches by 17 inches, and have the same form and content as Form DFS-F4-1548, “Workers’ Comp Works For You” Poster, (Rev 3/10), or Form DFS-F4-2026, “Compensación por accidentes de trabajo labora para usted” Poster, (Rev. 03/10), which are incorporated herein by reference. Form DFS-F4-1548 can be found at the following link: https://www.flrules.org/Gateway/reference.asp?No=Ref-13906; or on the Division’s website at: https://www.myfloridacfo.com/Division/WC/PublicationsFormsManualsReports/Brochures/Broken_Arm_Eng.pdf. Form DFS-F4-2026 can be found at the following link: https://www.flrules.org/Gateway/reference.asp?No=Ref-13907; or on the Division’s website at: https://www.myfloridacfo.com/Division/WC/PublicationsFormsManualsReports/Brochures/Broken_Arm_Span.pdf. The compensation notice may be posted separately or may be included as a part of a Florida and federal labor law poster.

(b) As an alternative to having the Anti-Fraud Reward Program language in the poster itself, the employer may elect to attach the Anti-Fraud Reward Program Notice to the poster on a separate piece of paper, with the same form and content as Form DFS-F4-1603, “Anti-Fraud Reward Program” Notice, (Eff. 2/2022), or Form DFS-F4-1604, “Programa de Recompesa en contra del Fraude,” (Eff. 2/2022), which are incorporated herein by reference. Form DFS-F4-1603 can be found at the following link: https://www.flrules.org/Gateway/reference.asp?No=Ref-14431; or on the Division’s website at: https://www.myfloridacfo.com/Division/WC/pdf/Anti-FraudNotice.pdf. Form DFS-F4-1604 can be found at the following link: https://www.flrules.org/Gateway/reference.asp?No=Ref-14432; or on the Division’s website at: https://www.myfloridacfo.com/Division/WC/pdf/Anti-FraudNotice-Spanish.pdf.

(2) The following information shall, in addition to subsection (1), above, be included on the compensation notice if the employer is insured through a commercial insurer:

(a) The name and address of the employer; and,

(b) The name and address of the insurer, the employer’s current workers’ compensation insurance policy number, the effective date of coverage of that policy and the expiration date of the policy.

(3) The following information shall, in addition to subsection (1), above, be included on the compensation notice if the employer is self-insured through a self-insurance fund:

(a) The name and address of the employer;

(b) The name of self-insurers fund to which the employer belongs;

(c) The employer’s membership number;

(d) The effective date of coverage; and,

(e) The service agent employer’s account number.

(4) The compensation notice may also include such other information, in addition to information required by subsections (1), (2), and (3), above, as the insurer or self-insurance fund may desire concerning accident reports, the names of physicians, or other pertinent information.

(5) Printers, insurers, self-insurers or self-insurance funds may obtain an electronic version of the art work for the compensation notices and the anti-fraud reward program notices from the Division’s website at https://www.myfloridacfo.com/Division/WC/.

Rulemaking Authority 440.40, 440.591 FS. Law Implemented 440.40 FS. History–New 11-20-79, Amended 4-15-81, 1-2-86, Formerly 38F-6.07, Amended 2-2-00, Formerly 38F-6.007, Amended 3-26-03, Formerly 4L-6.007, Amended 1-30-11, 2-15-16, 8-22-22.