Fla. Admin. Code Ann. R. 69L-3.025 - Forms

Current through Reg. 47, No. 188; September 28, 2021

(1) The following forms are to be used with this rule chapter and are hereby incorporated by reference:

(a) Form DFS-F2-DWC-1 3/16/09 First Report of Injury or Illness
(b) Form IA-1 1/1/02 Workers' Compensation First Report of Injury or Illness, © International Association of Industrial Accident Boards and Commissions (IAIABC) 2002. Note: Form IA-1 is to be used only by those entities approved to transmit electronic First Reports of Injury to the Division
(c) Form DFS-F2-DWC-1a 3/16/09 Wage Statement
(d) Form DFS-F2-DWC-4 3/16/09 Notice of Action/Change
(e) Form DFS-F2-DWC-12 3/16/09 Notice of Denial
(f) Form DFS-F2-DWC-13 3/16/09 Claim Cost Report
(g) Form DFS-F2-DWC-14 3/16/09 Request for Social Security Disability Benefit Information
(h) Form DFS-F2-DWC-19 3/16/09 Employee Earnings Report
(i) Form DFS-F2-DWC-30 3/16/09 Authorization and Request for Unemployment Compensation Information
(j) Form DFS-F2-DWC-33 3/16/09 Permanent Total Offset Worksheet
(k) Form DFS-F2-DWC-35 3/16/09 Permanent Total Supplemental Worksheet
(l) Form DFS-F2-DWC-40 3/16/09 Statement of Quarterly Earnings for Supplemental Income Benefits
(m) Form DFS-F2-DWC-60 03/10 Important Workers' Compensation Information for Florida's Workers
(n) Form DFS-F2-DWC-61 02/14 Informacion Importante De Seguro De Indemnizacion Por Accidentes De Trabajo Para Los Trabajadores De La Florida http://www.flrules.org/Gateway/reference.asp?No=Ref-04179
(o) Form DFS-F2-DWC-65 03/10 Important Workers' Compensation Information for Florida's Employers
(p) Form DFS-F2-DWC-66 03/10 Informacion Importante Del Seguro De Indemnizacion Por Accidentes De Trabajo Para Los Empleadores De La Florida
(2) The Division will not supply the forms promulgated under this chapter, but will make sample forms available on the Division's web site: http://www.myfloridacfo.com/division/WC/.


Fla. Admin. Code Ann. R. 69L-3.025

Rulemaking Authority 440.15, 440.185, 440.20, 440.591 FS. Law Implemented 440.02, 440.05, 440.102, 440.107, 440.12, 440.13, 440.14, 440.15, 440.16, 440.185, 440.19, 440.191, 440.192, 440.20(2), (3), 440.21, 440.34(3), 440.345, 440.35, 440.40, 440.491, 440.51(6), (9) FS.

New 4-11-90, Amended 1-30-91, 11-8-94, 11-11-96, 11-25-96, Formerly 38F-3.025, 4L-3.025, Amended 1-10-05, 3-16-09, 11-30-10, Amended by Florida Register Volume 40, Number 117, June 17, 2014 effective 6-30-14.

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