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First Report Of Injury Florida Form in PDF

The First Report of Injury form is an essential document for reporting workplace injuries or illnesses in Florida. This form is used by employers to notify the Florida Division of Workers' Compensation about an employee's injury or illness, ensuring that the necessary steps are taken for workers' compensation claims. Timely submission of this form is crucial for both the employee's rights and the employer's compliance with state regulations.

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First Report Of Injury Florida Form in PDF

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The First Report of Injury Florida form is a crucial document for both employees and employers in the event of a workplace injury or illness. This form serves as the initial notification to the Florida Department of Financial Services, Division of Workers' Compensation, detailing essential information about the incident. Key sections include employee information such as name, social security number, and occupation, alongside details of the accident, including its cause and the affected body part. Employers must provide their company name, federal ID number, and nature of business, as well as confirm the employee's employment status at the time of the incident. The form also addresses wage payments during the recovery period and includes specific dates related to the injury and the employee's work history. Importantly, it emphasizes the legal implications of filing false information, thereby ensuring the integrity of the claims process. By accurately completing this form, both parties can facilitate timely access to workers' compensation benefits and support the injured employee’s recovery journey.

Form Example

FIRST REPORT OF INJURY OR ILLNESS

FLORIDA DEPARTMENT OF FINANCIAL SERVICES

DIVISION OF WORKERS' COMPENSATION

For assistance call 1-800-342-1741 or contact your local EAO Office

PLEASE PRINT OR TYPE

RECEIVED BY	SENT TO DIVISION DATE	DIVISION RECEIVED DATE
CLAIMS-HANDLING ENTITY	SENT TO DIVISION DATE	DIVISION RECEIVED DATE
CLAIMS-HANDLING ENTITY

EMPLOYEE INFORMATION

NAME (First, Middle, Last)

Social Security Number

Date of Accident (Month-Day-Year)

Time of Accident

HOME ADDRESS

EMPLOYEE'S DESCRIPTION OF ACCIDENT (Include Cause of Injury)

Street/Apt #: _________________________________________________________

City: _________________________ State: _______________ Zip: ______________

TELEPHONE

Area Code

Number

OCCUPATION

INJURY/ILLNESS THAT OCCURRED

PART OF BODY AFFECTED

DATE OF BIRTH

SEX

_________ / _________ / _________

EMPLOYER INFORMATION

COMPANY NAME: ___________________________________________________

FEDERAL I.D. NUMBER (FEIN)

DATE FIRST REPORTED (Month/Day/Year)

D. B. A.: ____________________________________________________________

Street: _____________________________________________________________

NATURE OF BUSINESS

POLICY/MEMBER NUMBER

City: _________________________ State: _______________ Zip: ______________

TELEPHONE

Area Code

Number

DATE EMPLOYED

PAID FOR DATE OF INJURY

_________ / _________ / _________

YES

EMPLOYER'S LOCATION ADDRESS (If different)

LAST DATE EMPLOYEE WORKED

WILL YOU CONTINUE TO PAY WAGES INSTEAD OF

_________ / _________ / _________

WORKERS' COMP?

YES

Street: _____________________________________________________________

LAST DAY WAGES WILL BE PAID INSTEAD OF

RETURNED TO WORK

YES

City: ________________________ State: _______________ Zip: ______________

WORKERS' COMP

IF YES, GIVE DATE

LOCATION # (If applicable) ____________________________________________

_________ / _________ / _________

RATE OF PAY

PLACE OF ACCIDENT (Street, City, State, Zip)

DATE OF DEATH (If applicable)

_________ / _________ / _________

$ _________________ PER

Street: _____________________________________________________________

DAY

City: _________________________ State: _______________ Zip: ______________

AGREE WITH DESCRIPTION OF ACCIDENT?

Number of hours per day

______________________

COUNTY OF ACCIDENT ______________________________________________

YES

Number of hours per week

______________________

Number of days per week

______________________

Any person who, knowingly and with intent to injure, defraud, or deceive any employer or

employee, insurance company, or self-insured program, files a

NAME, ADDRESS AND TELEPHONE

statement of claim containing any false or misleading information commits insurance fraud, punishable as provided in s. 817.234. Section 440.105(7),

OF PHYSICIAN OR HOSPITAL

F.S.

I have reviewed, understand and acknowledge the above statement.

__________________________________________________________________		_______________________________________________
	EMPLOYEE SIGNATURE (If available to sign)	DATE
__________________________________________________________________		_______________________________________________
	EMPLOYER SIGNATURE	DATE		AUTHORIZED BY EMPLOYER		YES	NO
		CLAIMS-HANDLING ENTITY INFORMATION
1(a)	Denied Case - DWC-12, Notice of Denial Attached	2. Medical Only which became Lost Time Case (Complete all required information in #3)
1(b)	Indemnity Only Denied Case - DWC-12, Notice of Denial Attached	Employee’s 8TH Day of Disability			_________ / _________ / _________
		Entity’s Knowledge of 8TH Day of Disability			_________ /_________ / _________
3. Lost Time Case - 1st day of disability _________ / _________ / _________ Full Salary in lieu of comp?			YES	Full Salary End Date ________/ ________ / ________
Date First Payment Mailed _________ / _________ / _________		AWW ____________________________		Comp Rate ____________________________

T.T.

T.T. - 80%

T.P.

I.B.

P.T.

DEATH

SETTLEMENT ONLY

Penalty Amount Paid in 1st Payment $___________

Interest Amount Paid in 1st Payment $__________

REMARKS:

INSURER CODE #	EMPLOYEE'S CLASS CODE	EMPLOYER'S NAICS CODE

INSURER NAME

CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE

SERVICE CO/TPA CODE #

CLAIMS-HANDLING ENTITY FILE #

Form DFS-F2-DWC-1 (10/2016) Rule 69L-3.025, F.A.C.

DWC-1 Purpose and Use Statement

The collection of the social security number on this form is specifically authorized by Section 440.185(2), Florida Statutes. The social security number will be used as a unique identifier in Division of Workers' Compensation database systems for individuals who have claimed benefits under Chapter 440, Florida Statutes. It will also be used to identify information and documents in those database systems regarding individuals who have claimed benefits under Chapter 440, Florida Statutes, for internal agency tracking purposes and for purposes of responding to both public records requests and subpoenas that require production of specified documents. The social security number may also be used for any other purpose specifically required or authorized by state or federal law.

⇩ First Report Of Injury Florida File

Document Breakdown

Fact Name	Fact Description
Form Purpose	The First Report of Injury form is used to report workplace injuries or illnesses in Florida, ensuring compliance with state workers' compensation laws.
Governing Law	This form is governed by Chapter 440 of the Florida Statutes, which outlines the workers' compensation system in the state.
Required Information	Key information such as the employee's name, date of accident, and employer details must be included to process claims efficiently.
Submission Deadline	Employers are required to submit the form within seven days of learning about the injury to comply with Florida regulations.
Fraud Warning	The form includes a warning about insurance fraud, highlighting the seriousness of providing false information when filing a claim.

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