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B. Full Salary in lieu of comp AWW P. T. DEATH Full Salary End Date / / Comp Rate SETTLEMENT ONLY Interest Amount Paid in 1st Payment REMARKS INSURER NAME INSURER CODE EMPLOYEE S CLASS CODE SERVICE CO/TPA CODE Form DFS-F2-DWC-1 03/2009 Rule 69L-3. FIRST REPORT OF INJURY OR ILLNESS RECEIVED BY CLAIMS-HANDLING ENTITY SENT TO DIVISION DATE DIVISION RECEIVED DATE FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS COMPENSATION For assistance call 1-800-342-1741 or contact your local EAO...
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/City Code Telephone (or E-mail) EMPLOYEE CURRENT EMPLOYMENT: CITY/TOWN EMPLOYEE # — CUSTOMER'S NAME EMPLOYER's ADDRESS Phone — (or E-mail) EMPLOYEE LABEL/BIOS CARD NUMBER EMPLOYEE NAME EMPLOYMENT (FULL Surname) — — EMPLOYEE # NAME EMPLOYMENT EMPLOYEE STATUS (Employee Status) — — E-MAIL ADDRESS FEE HANDLING SERVICE (if any, fee may apply) Number of Persons — — FEE HANDLING SERVICE REQUIRED LAID/HELP NEEDED FOR DIVISION Report accidents and illnesses by calling, by mail or by submitting the online reporting form. For all reports, call or complete the online reporting form. You can report injuries quickly with the help of an ICD-10 Reportable Injury Form (T32). For more information, use the online reporting form and call. For help, call. Click here for more information about how to report work-related injuries. Please note: All information is collected for quality review purposes only by the Department of Financial Services. It is not a consumer report. Any information that you provide will remain your confidential information and the Division of Insurance and Workers' Compensation does not have access to this information in any way.

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