Permanent Total Off-Set Worksheet {DWC-33}

SENT TO DIVISION DATE DIVISION RECEIVED DATE PERMANENT TOTAL OFF-SET WORKSHEET FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS COMPENSATION 200 East Gaines Street TALLAHASSEE, FLORIDA 32399-4224  SOCIAL SECURITY #: EMPLOYEE NAME: (First, Middle, Last) DATE OF ACCIDENT: (Month-Day-Year) DATE OF BIRTH: (Month-Day-Year) EMPLOYER NAME: DATE ACCEPTED/ADJUDICATED PT: (Month-Day-Year) FORMULA: 1. Convert monthly benefits to weekly benefits by dividing the monthly amount by 4.3. 2. Add Compensation Rate + Primary Insurance Amount (PIA) or t he Maximum Family Benefits (MFB) if the employee has dependents. 3. Add five percent (5%) permanent total supplemental benefits for dates of accident prior to October 1, 2003. For dates of accident on or after October 1, 2003, add three percent (3%) permanent total supplemental benefits. Use Weekly Supplemental Rate at time of PT acceptance. 4. Subtract the greater of 80% Average Weekly Wage (AWW) or 80% Weekly Average Current Earnings (ACE). 5. Resulting difference is the offset amount (which shall not exceed the Initial Social Security Benefit). BENEFITS INFORMATION (Monthly/Weekly) Weekly Compensation __________________________ Average Weekly Wage __________________________ multiplied by .80 = 80% AWW _______________________ Monthly PIA _________________________ divided by 4.3 = Weekly PIA _______________________ Monthly ACE _________________________ divided by 4.3 = Weekly ACE _______________________ Maximum Family Benefit __________________________ divided by 4.3 = Weekly MFB _______________________ Offset Calculation _______________________________ Weekly Compensation (or applicable Maximum rate ) [ + ] _______________________________ Weekly PIA or MFB (whichever is applicable) [ + ] _______________________________ 5% PT Supplemental ( 3% for injuries occurring on or after October 1, 2003) [ = ] _______________________________ Combined Weekly Benefits [ - ] _______________________________ Greater of 80% AWW or 80% Weekly ACE [ a ] ______________________________ Total Offset Available (shall not exceed applicable PIA or MFB) weekly compensation [ b ] ______________________________ Offset Against Supplements (Division paid claims only) [ c ] ______________________________ Offset Against Compensation [ d ] ______________________________ Total Benefits Payable After Offset (Comp Rate-c=d) Effective _____________________ the Division / Claims-handling entity in accordance with Section 440.15(9) F.S., will begin applying the Social Security Offset to this case. Please attach a copy of the completed Form DFS-F2-DWC-14, Reque st for Social Security Disability Benefit Information and Form DFS-F2-DWC-4, Notice of Action/Change, as required by Rule 69L-3.0091, 69L-3.0194 and 69L-3.01945, F.A.C. 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. INSURER CODE # ADJUSTER NAME INSURER NAME: CLAIMS-HANDLING ENTITY NA ME, ADDRESS AND TELEPHONE SERVICE CO/TPA CODE # CLAIMS-HANDLING ENTITY FILE # Form DFS-F2-DWC-33 (08/2004)