69H-2.008. Other Forms Adopted

(1) The following forms are incorporated herein by reference. These forms shall be used to aid the Division in the performance of its administrative duties by securing pertinent facts and information on claims filed against the Fund, as the circumstances of particular cases may require.

(a) DFS-D0-280, Release of All Claims, (Effective 07/23), http://www.flrules.org/Gateway/reference.asp?No=Ref-15477;

(b) DFS-D0-866, “Mileage Reimbursement,” (Effective 07/23), http://www.flrules.org/Gateway/reference.asp?No=Ref-15484;

(c) DFS-D0-1403, “General Liability Loss Report,” (Effective 07/23), http://www.flrules.org/Gateway/reference.asp?No=Ref-15487;

(d) DFS-D0-1404, “Lien Disclosure Statement,” (Rev. 11/05);

(e) DFS-D0-1406, “Insurer’s Disclosure Statement Pursuant to Section 627.4137, F.S.,” (Rev. 11/05);

(f) DFS-D0-1407, “Medical Authorization,” (Rev. 2/10);

(g) DFS-D0-1408, Release for Property Damage Only (Effective 07/23) http://www.flrules.org/Gateway/reference.asp?No=Ref-15488.

(h) DFS-D0-1990, “Medicare Secondary Payer Reporting Questionnaire,” (Effective 07/23) http://www.flrules.org/Gateway/reference.asp?No=Ref-15489;

(i) DFS-D0-1991, “Medicare Beneficiary/Eligibility Information,” (Effective 07/23) http://www.flrules.org/Gateway/reference.asp?No=Ref-15490; and,

(j) DFS-D0-1992, Firefighter Cancer Benefit Information Form (Effective 07/23), http://www.flrules.org/Gateway/reference.asp?No=Ref-15491.

(2) Copies of each form adopted and incorporated by reference in this rule chapter are available from the Division of Risk Management, Department of Financial Services, 200 East Gaines Street, Tallahassee, Florida 32399-0336, or at https://myfloridacfo.com/Division/Risk/.

Rulemaking Authority 284.17, 284.39 FS. Law Implemented 284.30, 284.40, 284.41 FS. History–New 1-7-92, Amended 6-28-01, Formerly 4H-2.008, Amended 7-4-04, 5-4-05, 10-5-09, 1-9-11, 7-18-23.