⇨

Blank First Report Of Injury Florida PDF Form

The First Report of Injury Florida form is a crucial document designed for reporting workplace injuries or illnesses to the Florida Division of Workers' Compensation. This form helps ensure that employees receive the benefits they are entitled to following an accident at work. If you need to report an injury, don’t hesitate—fill out the form by clicking the button below.

Article Guide

The First Report of Injury form is a crucial document for both employees and employers in Florida, specifically designed to report workplace injuries or illnesses. This form serves as the initial step in the workers' compensation process, providing essential information about the incident. It captures details such as the employee's name, social security number, and the date and time of the accident, ensuring that the claim is properly documented. Additionally, it requires a description of the accident, including the cause of the injury, and specifies the part of the body affected. Employers must also provide their company information, including the federal identification number and the nature of their business. The form addresses critical questions regarding the employee's work status, such as whether wages will continue to be paid in lieu of workers' compensation. Furthermore, the form includes sections for both the employee and employer to sign, affirming the accuracy of the information provided. By meticulously completing this form, all parties involved can facilitate a smoother claims process, which ultimately aims to support the injured employee in their recovery and return to work.

Document Preview

FIRST REPORT OF INJURY OR ILLNESS

FLORIDA DEPARTMENT OF FINANCIAL SERVICES

DIVISION OF WORKERS' COMPENSATION

For assistance call 1-800-342-1741 or contact your local EAO Office

PLEASE PRINT OR TYPE

RECEIVED BY	SENT TO DIVISION DATE	DIVISION RECEIVED DATE
CLAIMS-HANDLING ENTITY	SENT TO DIVISION DATE	DIVISION RECEIVED DATE
CLAIMS-HANDLING ENTITY

EMPLOYEE INFORMATION

NAME (First, Middle, Last)

Social Security Number

Date of Accident (Month-Day-Year)

Time of Accident

HOME ADDRESS

EMPLOYEE'S DESCRIPTION OF ACCIDENT (Include Cause of Injury)

Street/Apt #: _________________________________________________________

City: _________________________ State: _______________ Zip: ______________

TELEPHONE

Area Code

Number

OCCUPATION

INJURY/ILLNESS THAT OCCURRED

PART OF BODY AFFECTED

DATE OF BIRTH

SEX

_________ / _________ / _________

EMPLOYER INFORMATION

COMPANY NAME: ___________________________________________________

FEDERAL I.D. NUMBER (FEIN)

DATE FIRST REPORTED (Month/Day/Year)

D. B. A.: ____________________________________________________________

Street: _____________________________________________________________

NATURE OF BUSINESS

POLICY/MEMBER NUMBER

City: _________________________ State: _______________ Zip: ______________

TELEPHONE

Area Code

Number

DATE EMPLOYED

PAID FOR DATE OF INJURY

_________ / _________ / _________

YES

EMPLOYER'S LOCATION ADDRESS (If different)

LAST DATE EMPLOYEE WORKED

WILL YOU CONTINUE TO PAY WAGES INSTEAD OF

_________ / _________ / _________

WORKERS' COMP?

YES

Street: _____________________________________________________________

LAST DAY WAGES WILL BE PAID INSTEAD OF

RETURNED TO WORK

YES

City: ________________________ State: _______________ Zip: ______________

WORKERS' COMP

IF YES, GIVE DATE

LOCATION # (If applicable) ____________________________________________

_________ / _________ / _________

RATE OF PAY

PLACE OF ACCIDENT (Street, City, State, Zip)

DATE OF DEATH (If applicable)

_________ / _________ / _________

$ _________________ PER

Street: _____________________________________________________________

DAY

City: _________________________ State: _______________ Zip: ______________

AGREE WITH DESCRIPTION OF ACCIDENT?

Number of hours per day

______________________

COUNTY OF ACCIDENT ______________________________________________

YES

Number of hours per week

______________________

Number of days per week

______________________

Any person who, knowingly and with intent to injure, defraud, or deceive any employer or

employee, insurance company, or self-insured program, files a

NAME, ADDRESS AND TELEPHONE

statement of claim containing any false or misleading information commits insurance fraud, punishable as provided in s. 817.234. Section 440.105(7),

OF PHYSICIAN OR HOSPITAL

F.S.

I have reviewed, understand and acknowledge the above statement.

__________________________________________________________________		_______________________________________________
	EMPLOYEE SIGNATURE (If available to sign)	DATE
__________________________________________________________________		_______________________________________________
	EMPLOYER SIGNATURE	DATE		AUTHORIZED BY EMPLOYER		YES	NO
		CLAIMS-HANDLING ENTITY INFORMATION
1(a)	Denied Case - DWC-12, Notice of Denial Attached	2. Medical Only which became Lost Time Case (Complete all required information in #3)
1(b)	Indemnity Only Denied Case - DWC-12, Notice of Denial Attached	Employee’s 8TH Day of Disability			_________ / _________ / _________
		Entity’s Knowledge of 8TH Day of Disability			_________ /_________ / _________
3. Lost Time Case - 1st day of disability _________ / _________ / _________ Full Salary in lieu of comp?			YES	Full Salary End Date ________/ ________ / ________
Date First Payment Mailed _________ / _________ / _________		AWW ____________________________		Comp Rate ____________________________

T.T.

T.T. - 80%

T.P.

I.B.

P.T.

DEATH

SETTLEMENT ONLY

Penalty Amount Paid in 1st Payment $___________

Interest Amount Paid in 1st Payment $__________

REMARKS:

INSURER CODE #	EMPLOYEE'S CLASS CODE	EMPLOYER'S NAICS CODE

INSURER NAME

CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE

SERVICE CO/TPA CODE #

CLAIMS-HANDLING ENTITY FILE #

Form DFS-F2-DWC-1 (10/2016) Rule 69L-3.025, F.A.C.

DWC-1 Purpose and Use Statement

The collection of the social security number on this form is specifically authorized by Section 440.185(2), Florida Statutes. The social security number will be used as a unique identifier in Division of Workers' Compensation database systems for individuals who have claimed benefits under Chapter 440, Florida Statutes. It will also be used to identify information and documents in those database systems regarding individuals who have claimed benefits under Chapter 440, Florida Statutes, for internal agency tracking purposes and for purposes of responding to both public records requests and subpoenas that require production of specified documents. The social security number may also be used for any other purpose specifically required or authorized by state or federal law.

➤ PDF File

Form Specifications

Fact Name	Description
Governing Law	The First Report of Injury form is governed by Florida Statutes, Chapter 440, which pertains to workers' compensation.
Form Purpose	This form is used to report workplace injuries or illnesses to the Florida Division of Workers' Compensation.
Submission Deadline	Employers must submit this report within seven days of learning about the injury or illness.
Employee Information	It requires detailed employee information, including name, social security number, and date of birth.
Accident Details	The form must include a description of the accident, including its cause and the time it occurred.
Employer's Responsibility	Employers are responsible for completing and submitting this form accurately to ensure proper claims processing.
Fraud Warning	The form includes a statement warning against filing false claims, which is considered insurance fraud.
Claims Handling	Employers must indicate whether the case is denied, medical only, or a lost time case on the form.
Contact Information	For assistance, individuals can call 1-800-342-1741 or reach out to their local Employee Assistance Office.
Social Security Number	The form collects the employee's social security number, which is used as a unique identifier in the compensation database.

First Report Of Injury Florida: Usage Guidelines

Completing the First Report of Injury Florida form is essential for documenting workplace injuries or illnesses. Once the form is filled out, it will be submitted to the appropriate claims-handling entity for processing. Ensure all information is accurate to avoid delays in the claims process.

Begin by entering the date the form is being filled out.
Fill in the employee information section:

Write the employee's full name (First, Middle, Last).
Provide the employee's social security number.
Indicate the date and time of the accident.
Enter the employee's home address, including street, city, state, and zip code.
Include the employee's telephone number.
Specify the employee's occupation.
Describe the injury or illness that occurred.
Identify the part of the body affected.
Enter the employee's date of birth and sex.

Proceed to the employer information section:

Fill in the company name and federal I.D. number.
Provide the date the injury was first reported.
Include the company's "doing business as" (D.B.A.) name.
Enter the employer's address, including street, city, state, and zip code.
Indicate the nature of the business and the policy/member number.
Provide the employer's telephone number.
Specify the date the employee was hired and if they were paid for the date of injury.
Enter the last date the employee worked.
Indicate if wages will continue to be paid instead of workers' compensation.
Provide the last day wages will be paid.

Complete the accident details section:

Enter the place of the accident (street, city, state, zip).
Specify the date of death if applicable.
Indicate the number of hours worked per day, week, and days per week.
State whether the description of the accident is agreed upon.

In the physician or hospital information section, provide the name, address, and telephone number of the treating physician or hospital.
Obtain the necessary signatures from the employee and employer, if available.
Complete any additional information required for the claims-handling entity.

Your Questions, Answered

What is the First Report of Injury Florida form?

The First Report of Injury form is a document used in Florida to report workplace injuries or illnesses. It is essential for initiating a workers' compensation claim. The form captures important details about the employee, the accident, and the employer, ensuring that all necessary information is collected for proper processing of the claim.

Who needs to fill out this form?

This form must be completed by the employer or their representative when an employee suffers a work-related injury or illness. The employee may also provide input, particularly regarding the details of the accident. It’s crucial for both parties to ensure the information is accurate to avoid complications in the claims process.

What information is required on the form?

The form requires several key pieces of information, including the employee's name, Social Security number, date and time of the accident, home address, occupation, and a description of the injury. Additionally, details about the employer, such as the company name, federal ID number, and nature of business, must be included. This comprehensive data helps streamline the claims process.

When should the form be submitted?

The First Report of Injury form should be submitted as soon as possible after the incident occurs. Prompt reporting is vital because it helps ensure that the employee receives the necessary medical care and benefits without unnecessary delays. Ideally, the form should be completed within seven days of the injury.

What happens after the form is submitted?

Once submitted, the form is reviewed by the claims-handling entity, which is responsible for processing the claim. They will assess the information provided and determine the next steps, which may include medical evaluations or further documentation requests. The employee will be notified of the claim's status and any benefits they may be entitled to.

Can the form be submitted electronically?

Yes, many employers choose to submit the First Report of Injury form electronically. This method can expedite the claims process and reduce paperwork. However, it’s essential to ensure that the electronic submission complies with all regulatory requirements and that confirmation of receipt is obtained.

What if the information on the form is incorrect?

If any information on the First Report of Injury form is found to be incorrect, it is crucial to address it immediately. The employer or claims-handling entity should submit a corrected form with the accurate details. Providing false information can lead to complications, including potential allegations of fraud.

Is there a deadline for filing a workers' compensation claim?

Yes, in Florida, there is a deadline for filing a workers' compensation claim, which is typically within two years from the date of the injury or illness. However, it’s best to report the injury and submit the First Report of Injury form as soon as possible to avoid missing any important deadlines that could affect the employee's eligibility for benefits.

What should I do if my claim is denied?

If your claim is denied, you have the right to appeal the decision. The first step is to carefully review the denial letter to understand the reasons behind it. You can then gather any additional documentation or evidence that supports your case and submit an appeal to the appropriate authority. Seeking assistance from a workers' compensation attorney can also be beneficial in navigating this process.

Common mistakes

Incomplete Employee Information: Failing to provide complete details about the employee can lead to delays in processing the claim. Ensure that the employee's name, social security number, and contact information are filled out accurately.
Incorrect Date of Accident: Entering the wrong date can complicate the claims process. Double-check the date of the accident to ensure it matches the incident report.
Vague Description of Accident: Providing a vague or unclear description of how the injury occurred can result in misunderstandings. Be specific about the cause of the injury and include relevant details.
Missing Signatures: Not signing the form or missing the employer's signature can halt the processing of the claim. Make sure both the employee and employer sign the form where required.

Documents used along the form

The First Report of Injury Florida form is an essential document for reporting workplace injuries. However, several other forms and documents often accompany it to ensure proper processing and compliance with workers' compensation laws. Below is a list of these forms, each serving a specific purpose in the claims process.

DWC-12, Notice of Denial: This document is used when a claim is denied. It outlines the reasons for the denial and provides the injured employee with necessary information regarding their rights and options for appeal.
DWC-1, Employee’s Claim for Compensation: This form is completed by the injured employee to formally request workers' compensation benefits. It includes details about the injury and the circumstances surrounding it.
Medical Records: These documents provide evidence of the injury and treatment received. They are crucial for substantiating the claim and determining the appropriate benefits.
Employer’s Report of Injury: This form is filled out by the employer to document the incident from their perspective. It includes details about the employee, the nature of the injury, and any witness statements.
Return-to-Work Form: This document is used to confirm that the injured employee is fit to return to work, either full-time or with restrictions. It is often required before resuming duties.
Claim for Compensation for Death: In cases of fatal workplace injuries, this form is used by dependents or beneficiaries to claim compensation for lost wages and benefits.
Independent Medical Examination (IME) Report: An IME may be requested to assess the employee’s condition and determine the extent of their injuries. The report is used to evaluate the validity of the claim.
Wage Loss Verification Form: This form is used to document any wage loss due to the injury. It helps determine the amount of compensation owed to the employee.
Settlement Agreement: If a claim is settled, this document outlines the terms of the settlement, including any payments to be made to the injured employee.

These documents work together with the First Report of Injury to create a comprehensive picture of the incident and its aftermath. Properly completing and submitting these forms can significantly impact the outcome of a workers' compensation claim.

Similar forms

Workers' Compensation Claim Form: This form is used to report a work-related injury or illness. Like the First Report of Injury, it collects information about the employee, the incident, and the employer. Both forms aim to initiate the workers' compensation process.
Incident Report: An incident report documents the details of an accident or injury. Similar to the First Report of Injury, it includes descriptions of what happened, where it occurred, and who was involved. Both forms serve to ensure accurate records for future reference.
Employee Injury Report: This report focuses on the employee's perspective of the injury. It gathers information on the nature of the injury and circumstances surrounding it. The First Report of Injury also collects this information, emphasizing the employee's account of the accident.
Employer's Report of Injury: This document is filled out by the employer to provide details about the injury from their viewpoint. Like the First Report of Injury, it includes information about the employee, the incident, and any actions taken afterward. Both forms are essential for filing a claim.
Medical Report: A medical report is prepared by healthcare providers to detail the diagnosis and treatment of the injured employee. It complements the First Report of Injury by providing medical insights into the injury, which are crucial for processing claims.

Dos and Don'ts

Filling out the First Report of Injury form in Florida is a crucial step for employees who have sustained an injury or illness at work. To ensure that the process goes smoothly, here are ten essential do's and don'ts to keep in mind.

Do provide complete and accurate information.
Do include the exact date and time of the accident.
Do describe the accident in detail, including the cause of the injury.
Do sign the form if you are able to do so.
Do keep a copy of the completed form for your records.
Don't leave out any required fields, such as your Social Security number.
Don't provide misleading or false information.
Don't forget to check your employer's location address if it's different from the company address.
Don't neglect to include your occupation and the part of your body affected by the injury.
Don't submit the form without reviewing it for errors or omissions.

By following these guidelines, you can help ensure that your report is processed efficiently, allowing you to receive the necessary support and benefits following your injury.

Misconceptions

Misconception 1: The First Report of Injury form is only necessary for severe injuries.

This form is required for all work-related injuries or illnesses, regardless of severity. Even minor incidents should be reported to ensure proper documentation and compliance with workers' compensation regulations.

Misconception 2: Only the employer can submit the First Report of Injury form.

While the employer typically submits the form, employees can also report their injuries. It is important for employees to ensure that their injuries are documented accurately, which may involve submitting the form themselves.

Misconception 3: The form must be completed immediately after the injury occurs.

Although timely reporting is important, the form does not have to be completed immediately. Employees should focus on receiving necessary medical attention first. However, it is advisable to fill out and submit the form as soon as possible after the incident.

Misconception 4: Submitting the form guarantees compensation for the injury.

Filing the First Report of Injury does not automatically ensure that compensation will be granted. Claims are reviewed by the workers' compensation insurance provider, and various factors are considered before a decision is made.

Misconception 5: The information on the form is not confidential.

Information provided on the First Report of Injury form is treated with confidentiality. It is used primarily for workers' compensation purposes and is protected under privacy laws. Employers and insurance companies are required to handle this information responsibly.

Key takeaways

Filling out the First Report of Injury Florida form is a crucial step in initiating a workers' compensation claim. Understanding the key aspects of this form can significantly impact the process and outcome of a claim. Here are five essential takeaways:

Accurate Information is Vital: Ensure that all sections of the form are completed with precise details. This includes the employee's name, date of accident, and a thorough description of the incident.
Timeliness Matters: Submit the form promptly after the injury occurs. Delays can complicate the claims process and may affect the benefits received.
Employer's Responsibilities: Employers must also complete their sections accurately, including the company name, federal ID number, and the date the injury was first reported.
Legal Implications: Be aware that providing false information on this form can lead to serious legal consequences, including charges of insurance fraud.
Follow-Up is Necessary: After submitting the form, maintain communication with the claims-handling entity to ensure that the claim is being processed and to address any additional requirements that may arise.