Response To Petition For Benefits

STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS OFFICE OF THE JUDGES OF COMPENSATION CLAIMS ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) Employee/Claimant, v. OJCC Case No.: Assigned Judge: Accident Date: Employer, and Carrier/Servicing Agent. ___________________________________ RESPONSE TO PETITION FOR BENEFITS LOST TIME CASE: (Y/N) RESPONSE TO EACH BENEFIT REQUESTED: (If Denial of Benefit(s) was rescinded, include the initial indemnity start date, disability type, average weekly wage and compensation rate.) MEDICAL BENEFITS CASE: (Y/N) DENIAL OF BENEFIT WAS RESCINDED ON: CARRIER: ADDRESS: TELEPHONE: ADJUSTER: TELEPHONE: CARRIER'S CODE: CARRIER'S FILE NO.: DATE PREPARED: COPY FURNISHED: ADDRESS: NOTICE: If you do not agree with the employer/carrier's action or you do not understand why you received this information, please contact your adjuster. For further assistance, please contact the Employee Assistance and Ombudsman Office at (800) 342-1741. OJCC Form RPFB (Revised 3-1-2007) American LegalNet, Inc. www.FormsWorkFlow.com