Notice of Action-Change {DWC-4}

SENT TO DIVISION DATE DIVISION RECEIVED DATE NOTICE OF ACTION/CHANGE DIVISION OF WORKERS COMPENSATION Attention: Information Management 200 East Gaines Street Tallahassee, FL 32399-4226 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  SOCIAL SECURITY NUMBER EMPLOYEE NAME (First, Middle, Last) DATE OF ACCIDENT (Month-Day-Year) INDICATE ONLY ACTION OR CHANGE - PLEASE REFER TO KEY FOR DWC-4 TYPES/CODES ON REVERSE SIDE 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 DATE FINAL SETTLEMENT ORDER MAILED: _________ - _________ - _________ OVERALL MMI DATE: _________ - _________- _________ PI RATING: __________ % BAW DATE OF DEATH _________ - _________ - _________ PERMANENT IMPAIRMENT BENEFITS (D/AS PRIOR TO 01/01/94): DATE PAID: _________ - _________ - _________ IMPAIRMENT INCOME BENEFITS (D/AS ON OR AFTER 01/01/94): START DATE: _________ - _________ - _________ WEEKLY RATE: $ _________________ TOTAL NUMBER OF WEEKS OF ENTITLEMENT: __________________ PERMANENT DATE ACCEPTED/ADJUDICATED _________ - _________- _________ AVERAGE WEEKLY WAGE AND/OR COMPENSATION RATE AMENDMENTS: TOTAL: WEEKLY PT SUPPLEMENTAL RATE $ ______________________________ PREVIOUS AWW: $ _______________________________ WEEKLY PT SUPP EFFECTIVE DATE _________ - _________- _________ PREVIOUS COMP RATE: $ _______________________________ BENEFIT ADJUSTMENTS AMENDED AWW: $ _______________________________ BENEFIT ADJUSTMENT __________ BENEFIT ADJUSTMENT __________ AMENDED COMP RATE: $ _______________________________ CODE CODE __________ __________ RETROACTIVE TO D/A: YES NO DISABILITY TYPE ADJUSTED DISABILITY TYPE ADJUSTED __________ __________ IF NO, GIVE EFFECTIVE DATE: _________ - _________- _________ WEEKLY ADJ AMOUNT $ WEEKLY ADJ AMOUNT $ __________ __________ EFFECTIVE DATE EFFECTIVE DATE __________ __________ ADJUSTMENT END DATE ADJUSTMENT END DATE CORRECTIONS OF: CLASS CODE SOCIAL SECURITY NUMBER/CORRECT #: ________________________________________________ DATE OF ACCIDENT/CORRECT DATE: _______________ - _______________ - ______________ NAICS CODE EMPLOYEES NAME/CORRECT NAME: ________________________________________________ CLAIMS-HANDLING ENTITY: ________________________________________________ REMARKS: ______________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________ CC: INSURER NAME INSURER CODE # DATE PREPARED: (Month-Day-Year) CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE _________ - _________ - _________ SERVICE CO/TPA CODE # CLAIMS-HANDLING ENTITY 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 commits insurance fraud, punishable as provided in s. 817.234. Section 440.105(7), F.S. Form DFS-F2-DWC-4 (08/2004) <<<<<<<<<********>>>>>>>>>>>>> 2 KEY FOR DFS-F2-DWC-4 TYPES / CODES DISABILITY TYPES: TT - Temporary Total Disability Benefits TTC - Temporary Total Disability Benefits at 80% for severe injuries per Section 440.15(2)(b), FS. TTE - Temporary Total Benefits while in an approved training and education program TP - Temporary Partial Disability Benefits PI - Permanent Impairment Benefits (Dates of Accident from 08/01/79 through 12/31/93) IB - Impairment Income Benefits (Dates of Accident on or after 01/01/94) WL - Wage Loss Benefits (Dates of Accident from 08/01/79 through 12/31/93) SB - Supplemental Benefits (Dates of Accident on or after 01/01/94) PT - Permanent Total Disability Benefits DB - Death Benefits SUSPENSION REASON CODES: (All Indemnity Benefits have been suspended because:) S1 - The employee returned to work, or was medically released to return to work S2 - The employee did not comply with medical treatment requirements in the Workers Compensation Law / Rules S3 - The employee did not comply with administrative requirements in the Workers Compensation Law / Rules S4 - The employee died S5 - The employee became incarcerated in a public institution S6 - The employees whereabouts are unknown S7 - The employees benefits have been used up or entitlement to those benefits has ended S8 - The employee claim has been changed to another jurisdiction BENEFIT ADJUSTMENT CODES: (The employees rate of pay is being reduced or adjusted because of:) A - Apportionment / Contribution from another insurer B - Subrogation / Third Party Recovery C - Overpayment of Benefits from the insurer H - Child Support Payment N - Employee not complying with Medical or Training and Education requirements P - Carrier taking credit for an advance given to the employee R - Social Security Retirement Benefits received by the employee S - Social Security Disability Benefits received by the employee U - Unemployment Compensation Benefits received by the employee V - A Safety Violation by the employee X - A change in the dependents entitled to Death Benefits Form DFS-F2-DWC-4 (08/2004)