Request For Wage Loss-Temporary Partial Benefits {DWC-3}

FLORIDA DEPARTMENT OF FINANCIAL SERVICES RECEIVED BY CLAIMS- SENT TO DIVISION DIVISION RECEIVED DIVISION OF WORKERS COMPENSATION HANDLING ENTITY DATE DATE REQUEST FOR WAGE LOSS/TEMPORARY PARTIAL BENEFITS 1-800-342-1741 or contact your local office for assistance COMPLETE ALL APPLICABLE SECTIONS BEFORE FILING WITH THE DIVISION  EMPLOYEE NAME (First, Middle, Last) & ADDRESS EMPLOYER NAME & ADDRESS SOCIAL SECURITY # TELEPHONE: TELEPHONE: DATE OF ACCIDENT: (Month-Day-Year) EMPLOYEE: You must complete one of these forms every two weeks. Complete and sign this section and submit to the claims-handlin g entity (adjuster) handling your claim. ARE YOU RECEIVING SOCIAL SECURITY? YES NO IF YES, AMOUNT $ ____________________ ARE YOU RECEIVING UNEMPLOYMENT COMPENSATION? YES NO IF YES, AMOUNT $ ___________________ I CLAIM LOSS OF WAGES FOR TWO WEEKS AS FOLLOW Week One _____/_____/_____ Week Two _____/_____/_____ I WAS EMPLOYED DURING THIS TWO WEEK PERIOD AS FOLLOWS: (Attach check stub or other documentation.) EMPLOYER NAME & ADDRESS __________________________________________________________________________________________ EMPLOYER TELEPHONE (_____) ________________________________________________________________________________________ Gross Wages: Week One $ ____________________ Week Two $ ____________________ I WAS NOT EMPLOYED AND LOOKED FOR EMPLOYMENT AS DOCUMENTED ON THE BACK OF THIS FORM. Upon making this claim and signing this document, I hereby authorize the release of Unemployment Compensation wage and benefit information and I hereby authorize the release of Social Security information. I declare that the facts reported herein are true to the best of my knowledge and I understand that any false or misleading statement I make could subject me to prosecution for fraud pursuant to Section 440.1051(3), Florida Statutes. 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 commits insurance fraud, punishable as provided in s. 817.234. Section 440.105(7), F.S. EMPLOYEE SIGNATURE __________________________________________________ DATE __________________________________________ CLAIMS-HANLDING ENTITY: Compute wage loss and complete other areas. Send employee copy with payment check and additional forms. Forward copy to employer (at time of injury) and to Division (upon request). WAGE LOSS: MMI Date _____/_____/_____ Rating __________% TEMPORARY PARTIAL CONTROVERTED - DWC-12 Attached WEEKS ONE: _____/_____/_____ to _____/_____/_____ WEEK TWO: _____/_____/_____ to _____/_____/_____ AWW-BEFORE INJURY ADJ. WW AWW-BEFORE INJURY ADJ. WW (Use applicable rate) __________ x __________ (Use applicable rate) __________ x __________ TOTAL GROSS EARNINGS TOTAL GROSS EARNINGS Discount Factor Applied? Yes No Deemed earnings Yes No Discount Factor Applied? Yes No Deemed earnings Yes No - - TOTAL WAGE LOSS = TOTAL WAGE LOSS = MULTIPLY BY APPLICABLE RATE x MULTIPLY BY APPLICABLE RATE x WAGE LOSS BENEFITS = WAGE LOSS BENEFITS = OFFSET (Identify benefits) - OFFSET (Identify benefits) - AMOUNT DUE/PAID = AMOUNT DUE/PAID = TOTAL AMOUNT PAID $ ____________________ Date _____/_____/_____ ADJUSTER NAME: INSURER NAME: DATE: _____/_____/_____ CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE: ADJUSTER SIGNATURE: Form DFS-F2-DWC-3 (08/2004) <<<<<<<<<********>>>>>>>>>>>>> 2NAME SOCIAL SECURITY NUMBER  WORK SEARCH REPORT DURING THE TWO-WEEK PERIOD CLAIMED, I HAVE ATTEMPTED TO FIND EMPL OYMENT WITHIN MY PHYSICAL AND VOCATIONAL CAPABILITIES AT EACH BUSINESS, EMPLOYMENT AGENCY AND JOB SERVICE OF FLORIDA LOCATION LISTED BELOW. DATE JOB CONTACT NAME, ADDRESS AND TELEPHONE APPLICATION RESULT OF APPLIED FOR PERSON NUMBER OF COMPANY FILED CONTACT YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO Form DFS-F2-DWC-3 (08/2004)