Most Commonly Used Forms

 

The forms used in workers' compensation are referred to by both the name of the form and the number. The number is at the bottom left hand side of the form. These forms are required by law and were created by the State of Florida Division of Workers’ Compensation, but they were sent to you by your employer’s insurance carrier. Below is a brief description of the most commonly used forms. If you have any questions about a form you received, call 800 342-1741 or e-mail your question towceao@myfloridacfo.com. To view a copy of a form click on the name of the form.

 

Notice of Action/Change

This form is sent to you, your employer and the Division of Workers’ Compensation to advise that the status of your claim has changed. There is a second page of the form that explains the abbreviations for the disability types, the suspension reason codes and the benefit adjustment codes. On the bottom portion of the form there is a section entitled “Remarks” where you can see written comments about the action/change.

 

Notice of Denial (DWC-12)

This form is used to advise you, your employer and the Division of Workers Compensation that the insurance carrier is totally or partially denying your claim. The first section below the employee and employer information, “Denied Benefits” will list the specific benefits that are being denied. The next section “Reason for Denial of Benefits” will give you the insurance carrier’s specific reason(s) for the denial of benefits.

Florida Workers’ Compensation Uniform Medical Treatment/Status Report Form (DWC-25): This form is used by your doctor to report to the insurance carrier the medical status of your claim. The form is very detailed and requires the doctor to determine if the injury is work related and that the injury is more than 50% responsible for your need for treatment. The doctor is also required to address your work status. You should ask your doctor for a copy of this form and be sure to provide a copy to your employer.

 

Employee Earnings Report (DWC-19)

This form is used to report any income you have while you are collecting workers’ compensation benefits. The insurance carrier may periodically request that you complete and return this form. Failure to complete and return the form within 10 days after you receive it may result in your benefits being suspended. When you are released to light duty work the insurance carrier will, within five days of their knowledge, also mail you the following letter, which explains your eligibility for Temporary Partial Disability Benefits.

 

“Your doctor has released you to return to work, but because of your work-related accident, you have been given restrictions on the type of work you can now do. Because you have not reached maximum medical improvement (the date after which your doctor says your injury will probably not get better), you may continue receiving workers’ compensation benefits approximately every two weeks if you are not able to earn at least 80% of the weekly wages you were making before your injury. 

(a) These benefits, called Temporary Partial Disability benefits, will be paid until: 
1. You reach maximum medical improvement or can return to work without restrictions;
 

2. You receive the maximum of 104 weeks allowed by law for either Temporary Total Disability benefits, Temporary Partial Disability benefits or Training and Education Temporary Total benefits, or 104 weeks for the combined benefits; or
 

3. You earn 80% or more of the weekly wages you were making at the time of your accident. 
(b) IMPORTANT: Temporary Partial Disability benefits may be stopped if:
 

1. You do not notify this office within five (5) business days after you return to work; 
 

2. You are not working due to your own misconduct on the job; 
 

3. You refuse suitable employment offered to you; or
 

4. You do not return, if requested, Form DFS-F2-DWC-19, “Employee Earnings Report”, as adopted in Rule 69L-3.025, F.A.C., to this claims office within 21 days after you receive it and report the receipt of any earnings, including Unemployment Compensation or Social Security benefits. You may be asked to complete, sign, and return this form once a month.
You are to notify this office immediately if you stop making at least 80% of your pre-injury weekly wages. However, if you leave your job without just cause as determined by a judge, your temporary partial disability benefits will be paid based on the amount of money you would have earned had you not left work. 
 

For more information about temporary partial disability benefits, please call the Employee Assistance Ombudsman Office (EAO) with the Division of Workers’ Compensation at any of its local offices listed in your “Important Workers’ Compensation Information For Florida Workers’ brochure, or at 1 (800) 342-1741."

 

Wage Statement (DWC-1a): This form is completed by your employer and sent to the insurance carrier to report your wages for the 13 weeks prior to your injury or illness. This is how the insurance carrier determines the amount of your lost wage benefits.

 

Request for Social Security Disability Benefit Information (DWC-14): This form is used by the insurance carrier to secure your authorization for the Social Security Administration to release your Social Security Benefits information to the insurance carrier. If you fail to complete and return this form upon request, your benefits may be suspended until you comply.