To revise forms to comply with the revision of Section 119.071(5), F.S. (2007), that precludes an agency from collecting an individual’s social security number unless such collection conforms to the specific provisions of that statute. Forms DFS-F2-...

DEPARTMENT OF FINANCIAL SERVICES
Division of Worker's Compensation

RULE NO: RULE TITLE
69L-3.0046: Wage Statement: Employer's and Claims-handling Entity's Responsibility to Record and Report Wages
69L-3.025: Forms
PURPOSE AND EFFECT: To revise forms to comply with the revision of Section 119.071(5), F.S. (2007), that precludes an agency from collecting an individual’s social security number unless such collection conforms to the specific provisions of that statute. Forms DFS-F2-DWC-1a (Wage Statement) and DFS-F2-DWC-30 (Authorization and Request for Unemployment Compensation Information) are amended so that the collection of the social security number is discontinued. Forms DFS-F2-DWC-1 (First Report of Injury or Illness), DFS-F2-DWC-3 (Request for Wage Loss/Temporary Partial Benefits), DFS-F2-DWC-4 (Notice of Action/Change), DFS-F2-DWC-12 (Notice of Denial), DFS-F2-DWC-13 (Claim Cost Report), DFS-F2-DWC-14 (Request for Social Security Disability Benefit Information), DFS-F2-DWC-19 (Employee Earnings Report), DFS-F2-DWC-33 (Permanent Total Off-Set Worksheet), DFS-F2-DWC-35 (Permanent Total Supplemental Worksheet), DFS-F2-DWC-40 (Statement of Quarterly Earnings for Supplemental Income Benefits), and DFS-F2-DWC-49 (Aggregate Claims Administration Change Report) are amended to include a purpose and use statement regarding collection of the social security number. This amendment also makes clerical revisions to the existing rules to be consistent with these revisions.
SUMMARY: Revision of forms to either eliminate the collection of social security numbers or to include a purpose and use statement explaining such collection.
SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS: No Statement of Estimated Regulatory Cost was prepared.
Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.
SPECIFIC AUTHORITY: 440.14, 440.15, 440.185, 440.185(5), 440.20, 440.345, 440.591 FS.
LAW IMPLEMENTED: 440.12(2), 440.14(3), 440.15(1), (4), (9), (10), 440.185(4), (5), (9), (10), 440.20(2), (3), 440.345, 440.35, 440.51(6), (9) FS.
IF REQUESTED WITHIN 21 DAYS OF THE DATE OF THIS NOTICE, A HEARING WILL BE HELD AT THE DATE,TIME AND PLACE SHOWN BELOW(IF NOT REQUESTED, THIS HEARING WILL NOT BE HELD):
DATE AND TIME: Thursday, December 18, 2008, 9:00 a.m.
PLACE: 104J Hartman Bldg., 2012 Capital Circle S.E., Tallahassee, Florida
Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 5 days before the workshop/meeting by contacting: Robin Ippolito at [phone]. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Robin Ippolito, Bureau Chief, Bureau of Monitoring & Audit, Division of Workers’ Compensation, Department of Financial Services, 200 East Gaines Street, Tallahassee, Florida 32399-4225, phone [phone]

THE FULL TEXT OF THE PROPOSED RULE IS:

69L-3.0046 Wage Statement: Employer’s and Claims-handling Entity’s Responsibility to Record and Report Wages

(1) Employer’s responsibility: The employer shall report wage information to the claims-handling entity on Form DFS-F2-DWC-1a, as adopted in Rule 69L-3.025, F.A.C., pursuant to Section 440.14, F.S. The employer shall provide the claims-handling entity all required wage information within 14 days of the employer’s knowledge of a “lost time” or a “medical only to lost time case”.

(2) Claims-handling entity’s responsibility: The claims-handling entity shall compare Forms DFS-F2-DWC-1 and DFS-F2-DWC-1a, as adopted in Rule 69L-3.025, F.A.C., to confirm that the employee name, social security number or other identifying information, and the date of injury on the two forms are consistent.

Specific Authority 440.14, 440.185(5), 440.591 FS. Law Implemented 440.12(2), 440.185(5), (9) FS. History–New 1-10-05, Amended________.

 

69L-3.025 Forms.

(1) The following forms are to be used with this rule chapter and are hereby incorporated by reference:

 

(a)	Form DFS-F2-DWC-1	___8/04	First Report of Injury or Illness
(b)	Form IA-1	1/1/02	Workers’ Compensation First Report of Injury or Illness For use only by entities approved to transmit electronic First Reports of Injury to the Division
(c)	Form DFS-F2-DWC-1a	___ 8/04	Wage Statement
(d)	Form DFS-F2-DWC-3	___ 8/04	Request for Wage Loss/Temporary Partial Benefits
(e)	Form DFS-F2-DWC-4	___ 8/04	Notice of Action/Change
(f)	Form DFS-F2-DWC-12	___ 8/04	Notice of Denial
(g)	Form DFS-F2-DWC-13	___ 8/04	Claim Cost Report
(h)	Form DFS-F2-DWC-14	___ 8/04	Request for Social Security Disability Benefit Information
(i)	Form DFS-F2-DWC-19	___ 8/04	Employee Earnings Report
(j)	Form DFS-F2-DWC-30	___ 8/04	Authorization and Request for Unemployment Compensation Information
(k)	Form DFS-F2-DWC-33	___ 8/04	Permanent Total Off-Set Worksheet
(l)	Form DFS-F2-DWC-35	___ 8/04	Permanent Total Supplemental Worksheet
(m)	Form DFS-F2-DWC-40	___ 8/04	Statement of Quarterly Earnings for Supplemental Income Benefits
(n)	Form DFS-F2-DWC-49	___ 8/04	Aggregate Claims Administration Change Report
(o)	Form DFS-F2-DWC-60	8/04	Important Workers’ Compensation Information for Florida’s Workers
(p)	Form DFS-F2-DWC-61	8/04	Informacion Importante De Seguro De Indemnizacion Por Accidentes De Trabajo Para Los Trabajadores De La Florida
(q)	Form DFS-F2-DWC-65	8/04	Important Workers’ Compensation Information for Florida’s Employers
(r)	Form DFS-F2-DWC-66	8/04	Informacion Importante Del Seguro De Indemnizacion Por Accidentes De Trabajo Para Los Empleadores De La Florida

 

(2) The Division will not supply the forms promulgated under this chapter, but will make sample forms available on the Division’s web site: http://www.fldfs.com/wc.

(3) For a transitional period of 90 days from the effective date of this rule, an insurer or claims-handling entity may use forms identified and adopted in subsection 69L-3.025(1), F.A.C., or the corresponding form(s) in effect prior to the adoption of this rule. After the completion of the 90 day transitional period, only the forms adopted in this rule may be used.

Specific Authority 440.15, 440.185, 440.20, 440.591 440.345 FS. Law Implemented 440.14(3), 440.15(1), (4), (9), (10), 440.185(4), (5), (10), 440.20(2), (3), 440.345, 440.35, 440.51(6), (9) FS. 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,________.

NAME OF PERSON ORIGINATING PROPOSED RULE: Robin Ippolito, Bureau Chief, Bureau of Monitoring & Audit, Division of Workers’ Compensation
NAME OF AGENCY HEAD WHO APPROVED THE PROPOSED RULE: Alex Sink, Chief Financial Officer, Department of Financial Services
DATE PROPOSED RULE APPROVED BY AGENCY HEAD: September 12, 2008
DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAW: September 26, 2008