Request For Assistance Form - Division Of Workers' Compensation State Of Florida - 2008
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1
2REQUEST FOR ASSISTANCE
EMPLOYEE ASSISTANCE OFFICE
DO NOT WRITE IN THIS AREA
DATE STAMP
DIVISION OF WORKERS’ COMPENSATION
STATE OF FLORIDA
PLEASE PRINT THE FOLLOWING INFORMATION:
NAME:
SEQ#:
OFFICE ASSIGNED TO:
EMPLOYEE TELEPHONE #: (OR CONTACT NUMBER)
DATE/ACCIDENT:
TIME/ACC:
EMPLOYEE STREET ADDRESS:
WORKERS’ COMP. INSURANCE COMPANY:
INSURANCE CO. TELEPHONE: (
)
CITY:
ST:
ZIP CODE:
INSURANCE CO. ADDRESS:
COUNTY OF EMPLOYEE RESIDENCE:
EMPLOYER’S NAME (COMPANY) & ADDRESS:
CITY:
ST:
ZIP CODE:
CLAIM REPRESENTATIVE’S (ADJUSTER) NAME:
EMPLOYER’S TELEPHONE #: (
)
THE INFORMATION YOU SUPPLY WILL BE USED TO PROCESS YOUR REQUEST.
THE MORE COMPLETE AND SPECIFIC THE INFORMATION THE BETTER WE WILL BE ABLE TO SERVE YOU.
This form is to be used to request help to resolve a dispute over benefits due and not received from your Employer/Carrier.
YES
NO
ARE YOU REPRESENTED BY AN ATTORNEY? (CHECK BOX)
ATTORNEY’S NAME/BAR NUMBER:
ATTORNEY’S ADDRESS AND TELEPHONE #:
WHO IS REQUESTING ASSISTANCE? (CHECK THE BOX THAT APPLIES):
Employee
Health Care Provider
Employer
Carrier/TPA
Other (Describe Here):
WHAT IS THE PROBLEM AREA? PLEASE CHECK THE BOX THAT APPLIES.
ENTIRE CLAIM DENIED?
MEDICAL BILL NOT PAID?
CHECK LATE?
NEED A DOCTOR?
OTHER?
IMPORTANT
PLEASE USE THE SPACE ON THE BACK OF THIS FORM TO EXPLAIN, IN DETAIL, WHAT YOU NEED AND WHY
THE FOLLOWING ACTIONS SHOULD BE NOT FILED WITH THE EAO OFFICE:
**CLAIMS FOR S.D.T.F.
**CLAIMS FOR CONTRIBUTION
**ALL MOTIONS TO J.C.C.
**AMENDED PETITIONS
**REQUESTS FOR ATTORNEY’S FEES AND COSTS
EAO1-Rule_69L-26.002,F.A.C.
REV:4/21/08
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