Florida Division of Workers' Compensation Forms on Disc

Form #
Revision Date
Pages
 Title
AFSU-10
06/29/94
4
 Financial Affidavit
DWC-01
11/94
1
 First Report of Injury or Illness
DWC-01a
11/96
2
 Wage Statement
DWC-03
01/91
2
 Request for Wage Loss/Temporary Partial Benefits
DWC-04
11/94
2
 Notice of Action/Change
DWC-08
09/01/94
1
 Notification of Initial Treatment
DWC-09a
09/01/94
2
 Maximum Medical Improvement/Permanent Impairment Determination Certification Form
DWC-10
09/01/94
1
 Statement of Charges for Drugs and Medical Supplies
DWC-12
11/94
1
 Notice of Denial
DWC-13
11/94
1
 Claims Cost Report
DWC-14
11/94
1
 Request for Social Security Disability Benefit Information
DWC-19
11/94
1
 Employee Earnings Report
DWC-20
08/30/95
2
 Individualized Written Reemployment Plan
DWC-21
08/30/95
1
 Reemployment Services Reporting Form
DWC-22
08/30/95
1
 Reemployment and Annual Case Status Review Form
DWC-22a
08/30/95
2
 Request for Screening
DWC-24
08/30/95
2
 Agency and Student Agreement for Sponsorship of Retraining
DWC-30
11/94
1
 Authorization and Request for Unemployment
DWC-33
10/03/94
1
 Permanent Total Off-Set Worksheet
DWC-35
10/03/95
1
 Permanent Total Supplemental Worksheet
DWC-40
11/94
2
 Statement of Quarterly Earnings for Supplemental Income Benefits
DWC-48
11/94
1
 Monthly Risk Class/SIC Code Report
DWC-49
11/94
1
 Aggregate Claims Administration Change Report
DWC-51
11/96
2
 Aggregate Defense Attorney Fee Report
DWC-96
09/20/95
2
 Qualified Rehabilitation Provider Application
DWC-97
10/15/94
1
 Health Care Provider Application for Certification
DWC-98
01/20/95
1
 Expert Medical Advisor Application and Contract for Certification
EAO-1
06/17/94
2
 Request for Assistance
NCCI-9
05/07/96
1
 Application for Drug-Free Workplace Premium Credit Program
PW-2
06/94
1
 Preferred Worker Reimbursement Request
SDF-1
02/94
1
 Proof of Claim
SDF-2
03/92
7
 Reimbursement Request
SDF-6
08/98
1
 Explanation of Benefits
SI-001
09/96
3
 Application for Self-Insurance
SI-001a
09/96
3
 Re-Application for Self-Insurance
SI-004
09/96
1
 Surety Bond
SI-004b
09/96
1
 Self-Insurers Surety Bond
SI-005
09/96
1
 Self-Insurers Payroll Report
SI-006
09/96
2
 Sample Self-Insurers Irrevocable Letter of Credit
SI-011
09/96
2
 Indemnity Agreement
SI-017
09/96
1
 Self-Insurance Unit Statistical Report
SI-017NA
09/96
4
 Self-Insurance Unit Statistical Report (New Applicant)
SI-019
09/96
1
 Certification of Servicing for Self-Insurers
SI-020
09/96
1
 Report of Outstanding Workers' Compensation Liabilities
SI-022
09/96
1
 Service Company Application
SI-023
09/96
2
 Service Company Annual Report Form
SI-026
09/96
6
 Actuarial Report Checklist
SI-027
09/96
6
 Biographical Statement and Affidavit
SI-032
09/96
1
 Assignment of Securities
SI-206
09/96
1
 Certificate of Self Insurance
UCC-1
1993
2
 Uniform Commercial Code Financing Statement

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