Les Form Dwc-1 - First Report Of Injury Or Illness - Florida Dept. Of Labor & Employment Security - 1994
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1FLORIDA DEPT. OF LABOR & EMPLOYMENT SECURITY
RECEIVED BY CARRIER
SENT TO DIVISION
DIVISION REC'D DATE
DIVISION OF WORKERS' COMPENSATION
2728 Centerview Drive, 202 Forrest Building
Tallahassee, Florida 32399-0685
FIRST REPORT OF INJURY OR ILLNESS
For assistance call 1-800-342-1741
or contact your local EAO Office
Report all deaths within 24 hours 800-219-8953
PLEASE PRINT OR TYPE
EMPLOYEE INFORMATION
NAME (First, Middle, Last)
Social Security Number
Date of Accident (Month/Day/Year)
Time of Accident
AM
PM
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
_________ / _________ / _________
M
F
EMPLOYER INFORMATION
FEDERAL I.D. NUMBER (FEIN)
DATE FIRST REPORTED (Month/Day/Year)
COMPANY NAME: ___________________________________________________
D. B. A.: ____________________________________________________________
NATURE OF BUSINESS
POLICY/MEMBER NUMBER
Street: _____________________________________________________________
City: _________________________ State: _______________ Zip: ______________
TELEPHONE
Area Code
Number
DATE EMPLOYED
PAID FOR DATE OF INJURY
_________ / _________ / _________
YES
NO
LAST DATE EMPLOYEE WORKED
WILL YOU CONTINUE TO PAY WAGES INSTEAD OF
EMPLOYER'S LOCATION ADDRESS (If different)
WORKERS' COMP?
YES
_________ / _________ / _________
Street: _____________________________________________________________
LAST DAY WAGES WILL BE PAID INSTEAD OF
RETURNED TO WORK
YES
NO
WORKERS' COMP
City: _________________________ State: _______________ Zip: ______________
IF YES, GIVE DATE
LOCATION # (If applicable) _____________________________________________
_________ / _________ / _________
_________ / _________ / _________
DATE OF DEATH (If applicable)
RATE OF PAY
HR
WK
PLACE OF ACCIDENT (Street, City, State, Zip)
_________ / _________ / _________
$ _________________ PER
DAY
MO
Street: _____________________________________________________________
AGREE WITH DESCRIPTION OF ACCIDENT?
Number of hours per day
City: _________________________ State: _______________ Zip: ______________
______________________
YES
NO
Number of hours per week
______________________
COUNTY OF ACCIDENT ______________________________________________
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
NAME, ADDRESS AND TELEPHONE
OF PHYSICIAN OR HOSPITAL
program, files a statement of claim containing any false or misleading information is guilty of a felony of the third degree. I have reviewed,
understand and acknowledge the above statement.
__________________________________________________________________
_______________________________________________
EMPLOYEE SIGNATURE (If available to sign)
DATE
__________________________________________________________________
_______________________________________________
AUTHORIZED BY EMPLOYER
YES
NO
EMPLOYER SIGNATURE
DATE
CARRIER INFORMATION
1. Case Denied - DWC-12, Notice of Denial Attached
2. Medical Only which became Lost Time Case (Complete all info in #3)
3. Lost Time Case - 1st day of disability _________ / _________ / _________ Salary continued in lieu of comp?
YES
Salary End Date _________/ _________ / _________
Date First Payment Mailed _________ / _________ / _________
AWW ____________________________
Comp Rate ____________________________
T.T.
T.T. - 80%
T.P.
I.B.
P.T.
DEATH
REMARKS:
CARRIER NAME, ADDRESS & TELEPHONE
CARRIER CODE #
EMPLOYEE'S RISK CLASS CODE
EMPLOYER'S SIC CODE
SERVICE CO/TPA CODE #
CARRIER FILE #
YES
NO
Is employer self-insured?
LES Form DWC-1 (11/94)
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