Form Dwc-4 - Notice Of Action/change

CARRIER SENT TO DIVISION DATE

NOTICE OF ACTION/CHANGE

FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY

DIVISION OF WORKERS' COMPENSATION

2728 Centerview Drive, 202 Forrest Building

Tallahassee, FL 32399-0685

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

COMPLETE ALL APPLICABLE SECTIONS BEFORE FILING WITH THE DIVISION

PLEASE PRINT OR TYPE

EMPLOYEE NAME

SOCIAL SECURITY NUMBER

DATE OF ACCIDENT

INDICATE ONLY ACTION OR CHANGE - PLEASE REFER TO KEY FOR DWC-4 TYPES/CODES ON REVERSE SIDE

INITIAL INDEMNITY STARTED:

EFFECTIVE DATE

_______/_______/_______

DISABILITY TYPE:

______________________

ALL INDEMNITY SUSPENDED:

EFFECTIVE DATE

REASON CODE:

_______/_______/_______

______________________

INDEMNITY REINSTATED AFTER SUSPENSION:

EFFECTIVE DATE

DISABILITY TYPE:

_______/_______/_______

______________________

RELEASED TO RETURN TO WORK DATE:

_________ / _________ / _________

RESTRICTIONS?:

YES

NO

ACTUAL RETURN TO WORK DATE:

_________ / _________ / _________

RESTRICTIONS?:

YES

NO

FINAL INDEMNITY SETTLEMENT DATE:

_________ / _________ / _________

OVERALL MMI DATE:

PI RATING: __________% BAW

DATE OF DEATH _________ / _________ / _________

_________ / _________ / _________

PERMANENT IMPAIRMENT BENEFITS (D/A'S PRIOR TO 01/01/94):

DATE PAID:

_________ / _________ / _________

IMPAIRMENT INCOME BENEFITS (D/A'S ON OR AFTER 01/01/94):

START DATE:

WEEKLY RATE:

$_________________

_________ / _________ / _________

TOTAL # OF WEEKS OF ENTITLEMENT:

__________________

PERMANENT

DATE ACCEPTED/ADJUDICATED

_________ / _________ / _________

AVERAGE WEEKLY WAGE AND/OR COMPENSATION RATE AMENDMENTS:

TOTAL:

PT SUPPLEMENTAL RATE

$_____________________________

PREVIOUS AWW:

$_______________________________

PT SUPP EFFECTIVE DATE

PREVIOUS COMP RATE:

_________ / _________ / _________

$_______________________________

BENEFIT ADJUSTMENTS

AMENDED AWW:

$_______________________________

ADJUSTMENT TYPE

__________

ADJUSTMENT TYPE

__________

AMENDED COMP RATE:

$_______________________________

WEEKLY ADJ AMOUNT

WEEKLY ADJ AMOUNT

RETROACTIVE TO D/A:

__________

__________

YES

NO

EFFECTIVE DATE

EFFECTIVE DATE

IF NO, GIVE EFFECTIVE DATE:

__________

__________

_________ / _________ / _________

ADJUSTMENT END DATE

ADJUSTMENT END DATE

__________

__________

CORRECTIONS OF:

RISK CLASS CODE

________________________________________________

SOCIAL SECURITY NUMBER/CORRECT #:

DATE OF ACCIDENT/CORRECT DATE:

_______________ / _______________ / ______________

SIC CODE

________________________________________________

NAME/CORRECT NAME:

________________________________________________

CARRIER/SERVICING AGENT:

REMARKS:

______________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________

CC:

CARRIER CODE #

DATE PREPARED

CARRIER NAME, ADDRESS & TELEPHONE

_________ / _________ / _________

SERVICE CO/TPA CODE #

CARRIER FILE #

Any person who, knowingly and with intent to injure, defraud or deceive any employer or employee, insurance company or self-insured program, files a statement of claim containing any false or

misleading information is guilty of a felony of the third degree.

LES Form DWC-4 (11/94)