This area is only available to WorkCompResearch subscribers. WCR offers the most advanced Compliance and Regulatory Research System available.

Already a member? Log-in

Join Today for Immediate Access!


Sign Up


Home| Forms| Legal Library| Compliance| Calculators| State Comparisons| Reference Desk| What's New| Roundtable
Pre-select A State ↓ (Optional)   Current State: None   (← what's this?)

Florida Form Center -

Type & Print Forms - programmed for direct type and print functionality.

Each form may be downloaded in Adobe Acrobat format. Download the form by clicking on the form number below.
If you do not have Adobe Acrobat Reader, you may download it here for free. Download Adobe Here

All of these forms may now be auto-populated from your claims software program! Click here to learn about FlashForm SSL.


Form

Description

dwc1.pdf First Report of Injury or Illness
dwc1a.pdf Wage Statement
dwc3.pdf Request for Wage Loss/Temporary Partial Benefits
dwc4.pdf Notice of Action/Change
dwc12.pdf Notice of Denial
dwc13.pdf Claim Cost Report
dwc14.pdf Request for Social Security Disability Benefit Information
dwc19.pdf Employee Earnings Report
dwc26.pdf Department and Injured Employee Agreement for the Provision of Contracted Placement Services
dwc27.pdf Reemployment Services Questionnaire
dwc30.pdf Authorization and Request for Unemployment
dwc33.pdf Permanent Total Off-Set Worksheet
dwc35.pdf Permanent Total Supplemental Worksheet
dwc40.pdf Statement of Quarterly Earnings for Supplemental Income Benefits
dwc49.pdf Aggregate Claims Administration Change Report
dwc60.pdf BROCHURE - Important Workers' Compensation Information for Florida Workers
dwc61.pdf BROCHURE - Important Workers' Compensation Information for Florida Workers (Spanish)
dwc65.pdf BROCHURE - Important Workers Compensation Information for Florida Employers
dwc66.pdf BROCHURE - Important Workers Compensation Information for Florida Employers (Spanish)
DFWPman.pdf BROCHURE - An Employer's Guide to a Drug-Free Workplace
si-1.pdf Application for Self-Insurance
si-1G.pdf Application for Governmental Self-Insurance
si-4F.pdf Self-Insurer's Surety
si-5.pdf Self-Insurers Payroll Report
si-6.pdf Self-Insurers Irrevocable Letter of Credit
si-8.pdf Self-Insurers Application for Drug-Free Workplace Premium Credit Program
si-9.pdf Self-Insurance Certification of Workplace Safety Program Premium
si-10.pdf Parental Guaranty and Corporate Resolution
si-11.pdf Indemnity Agreement
si-17.pdf Unit Statistical Report
si-19.pdf Certification of Servicing for Self-Insurers
si-20.pdf Report of Outstanding Workers' Compensation Liabilities
si-22.pdf Qualified Servicing Entity Application
si-23.pdf Qualified Servicing Entity Annual Report
si-27.pdf Biographical Statement and Affidavit
si-GEP.pdf Application for Governmental Self-Insurance Estimated Payroll
dwc250.pdf DWC-250 Notice of Election to be Exempt is no longer available. You must apply online - https://apps.fldfs.com/bocexempt/
dwc250r.pdf Revocation of Election to be Exempt
dwc251.pdf Notice of Election of Coverage
dwc251r.pdf Revocation of Election of Coverage
dwc25.pdf Florida Workers' Compensation Uniform Medical Treatment/Status Report Form
dwc25instr.pdf Instructions for completion of the DWC-25
dwc9instr_asc.pdf Instructions for Completion of the Health Insurance Claim Form / HCFA-1500 (12-90) not available for download
dwc9instr_lhcp.pdf Instructions for Completion of the LES Form DWC-9 when Submitted by Licensed Health Care Providers
dwc9instr_whpm.pdf Instructions for Completion of the LES Form DWC-9 When Submitted by Work Hardening and Pain Management Programs
dwc10.pdf Statement of Charges for Drugs and Medical Supplies
dwc11instr.pdf Instructions for Dental Claim Form (J512)
ncci-9.pdf Application for Drug-Free Workplace Premium Credit Program
SDF-1.pdf Proof of Claim
SDF-2.pdf Reimbursement Request
SDF-6.pdf Explanation of Benefits
PW-2.pdf Preferred Worker Reimbursement Request
dwc23.pdf Request for Screening
dwc24.pdf Department and Student Agreement for Sponsorship of Training and Education
EAO-1.pdf Request for Assistance
dfs3160-0023.pdf Petition for Resolution of Reimbursement Dispute
dfs3160-0024.pdf Carrier Response to Petition for Resolution of Reimbursement Dispute
dwc-2000.pdf Health Care Provider Violation Referral Form
EDI-1.pdf Edi Trading Partner Profile
EDI-2.pdf Edi Trading Partner Insurer/Claim Administrator Id List
EDI-3.pdf Edi Transmission Profile - - Sender's Specifications
EDI-4.pdf Secure Socket Layer (SSL)/File Transfer Protocol (FTP) Instructions
Anti-FraudNotice.pdf POSTER - Anti-Fraud Poster
Anti-FraudNotice-Sp.pdf POSTER - Anti-Fraud Poster (Spanish)
BrokenArmPoster.pdf POSTER - Broken Arm Poster - 11 x 17 Size
BrokenArmPoster_sp.pdf POSTER - Broken Arm Poster - 11 x 17 Size (Spanish)
EmpNotLetter-1.pdf Employee Notification Letter
EmpNotLetter_sp.pdf Employee Notification Letter (Spanish)
jccRACN.pdf JCC - Request for Assignment of Case Number
UPPSampleFormB.pdf JCC - Doctor`s Estimate of Future Medical Expenses
jccPFB.pdf JCC - Petition for Benefits
jccResponsetoPFB.pdf JCC - Response to Petition for Benefit
UPPSampleFormC.pdf JCC - Addendum to Stipulation in Support of Petition for Order Approving a Lump-Sum Settlement
UPPSampleFormE.pdf JCC - Affidavit in Support of Attorney's Fees in Excess of Statutory Guideline
UPPSampleFormF.pdf JCC - Motion for Approval of Attorney Fee and Allocation of Child Support Arrearage for Settlements
VP_PayFilingFees.pdf JCC - Verified Petition - Relief from Paying Filing Fees
VP_PayPrepCosts.pdf JCC - Verified Petition - Relief from Paying Cost of Record Preparation
CC-PayFilingFees.pdf JCC - Certified Counsel - Relief from Paying Filing Fees
CC-PayPrepCosts.pdf JCC - Certified Counsel - Relief from Paying Cost of Record Preparation
FinancialAffidavit.pdf JCC - Financial Affidavit
VerifiedMotionSubstituteID.pdf JCC - Verified Motion for Assignment of Substitute Identification Number
jccAFDS.pdf JCC - Attorney Fee Data Sheet
AFDS-INT.pdf JCC - Attorney Fee Data Sheet - Attorney Fee Not in Connection with Settlement
AFDS-WOA.pdf JCC - Attorney Fee Data Sheet - Additional Attorney Fee in Connection with Settlement
AFDS-WO.pdf JCC - Attorney Fee Data Sheet - Washout Settlement
UniformStatewidePretrial.pdf JCC - Uniform Statewide Pretrial Stipulation
MediationRequest.pdf JCC - Joint Request for Voluntary Mediation OJCC Voluntary Mediation Program
EJCCAccessRequest.pdf JCC - Party's Request for Complete eJCC Access to Case
SuspendDefer.pdf JCC - Suspend and Defer Order
UnpaidSupportOwedRequest.pdf JCC - Request for Amount of Unpaid Support Owed
Ch119PublicRecordExemption.pdf JCC - CH 119 Public Record Exemption
ContactRegistration.pdf JCC - Contact Registration Form
WC-Reemployment-brochure.pdf BROCHURE - We Are Here 4 You Reemployment Services Program
mileage2.pdf Mileage Reimbursement Form
ucc-1.pdf Uniform Commercial Code Financing Statement
MEMIC_FL_MMI_Letter.pdf Memic Florida MMI Letter