Workers' Compensation - Florida - Free Forms and Publications

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Product	SKU	More Info
Florida "EDI Trading Partner Insurer/Claim Administrator ID List" (10/1/2006) [DFS-F5-DWC-EDI-2]	FFFL350
Florida "EDI Trading Partner Profile" (10/1/2006)	FFFL345
Florida "EDI Transmission Profile-Sender's Specifications" (10/1/2006) [DFS-F5-DWC-EDI-3]	FFFL355
Florida "Hurt at Work?"	FFFL410
Florida Actuarial Report Checklist (SI-26)	FFFL155
Florida Aggregate Claims Administration Change Report (DFS-F2-DWC-49)	FFFL065
Florida AHCA Health Facility and Agency Licensing 59A-31 Disputed Reimbursement Rules	FFFL290
Florida All-In-One Broken Arm poster	FFFL390
Florida Anti-Fraud Notice	FFFL400
Florida Application for Drug-Free Workplace Premium Credit Program (NCCI Form 09-1)	FFFL180
Florida Application for Self-Insurance (SI-1)	FFFL090
Florida Assignment of Securities (SI-32)	FFFL165
Florida Authorization and Request for Unemployment Compensation Information (DFS-F2-DWC-30)	FFFL045
Florida Biographical Statement and Affidavit (SI-27)	FFFL160
Florida Carrier Response to Petition for Resolution of Reimbursement Dispute (3160-0024)	FFFL285
Florida Certificate of Self Insurance (SI-206)	FFFL170
Florida Certification of Servicing for Self-Insurers (SI-19)	FFFL135
Florida Claim Cost Report (DFS-F2-DWC-12)	FFFL030
Florida Employee Earnings Report (DFS-F2-DWC-19)	FFFL040
Florida Employer Instruction Manual	FFFL365
Florida Employer's Guide to a Drug-Free Workplace	FFFL405
Florida Expert Medical Advisor Application and Contract For Certification (3160-0021)	FFFL270
Florida Explanation of Benefits (DFS-F1-SDF-6)	FFFL310
Florida First report of injury or illness (DFS-F2-DWC-1)	FFFL005
Florida Form used to request a duplicate certificate of election to be exempt.	FFFL210
Florida Health Care Provider Application for Certification (3160-0020)	FFFL265
Florida Health Care Provider Tutorial for Expert Medical Advisor Certification	FFFL275
Florida Health Provider Claim Form/CMS-1500 (DFS-F5-DWC-9)	FFFL220
Florida Important Workers' Compensation Information for Florida's Employers (DFS-F2-DWC-65)	FFFL080
Florida Important Workers' Compensation Information For Florida's Employers brochure	FFFL380
Florida Important Workers' Compensation Information For Florida's Employers brochure - Spanish	FFFL385
Florida Important Workers' Compensation Information For Florida's Workers brochure	FFFL370
Florida Important Workers' Compensation Information For Florida's Workers brochure - Spanish	FFFL375
Florida Indemnity Agreement (SI-11)	FFFL120
Florida Informacion Importante De Seguro De Indemnizacion Por Accidentes De Trabajo Para Los Trabaja (DFS-F2-DWC-61)	FFFL075
Florida Informacion Importante Del Seguro De Indemnizacion Por Accidentes De Trabajo Para Los Emplea	FFFL085
Florida Instructions for completing Notice of Election to be Exempt (DWC 250 Instructions)	FFFL190
Florida Instructions for completion of the DWC-11	FFFL250
Florida Instructions for completion of the DWC-9	FFFL225
Florida Instructions for completion of the UB-04.	FFFL260
Florida Join the Battle Against Workers' Compensation Fraud.	FFFL395
Florida Mileage Reimbursement Form - Download Version	FFFL335
Florida Mileage Reimbursement Form - New On-Line Version	FFFL340
Florida Notice of Action/Change (DFS-F2-DWC-4)	FFFL020
Florida Notice of Denial (DFS-F2-DWC-12)	FFFL025
Florida Notice of Election of Coverage (DWC 251)	FFFL200
Florida Notice of Election to be Exempt (DWC 250)	FFFL185
Florida Permanent Total Off-Set Worksheet (DFS-F2-DWC-33)	FFFL050
Florida Permanent Total Supplemental Worksheet (DFS-F2-DWC-35)	FFFL055
Florida Petition for Benefits (PFB)	FFFL325
Florida Petition for Resolution of Reimbursement Dispute (3160-0023)	FFFL280
Florida Preferred Worker Reimbursement Request (DFS-F1-PW-2)	FFFL320
Florida Proof of Claim (DFS-F1-SDF-1)	FFFL300
Florida Re-Application for Self-Insurance (SI-1a)	FFFL095
Florida Reimbursement Request (DFS-F1-SDF-2)	FFFL305
Florida Report of Outstanding Workers' Compensation Liabilities (SI-20)	FFFL140
Florida Request for Assistance (EAO-1)	FFFL330
Florida Request for Social Security Disability Benefit Information (DFS-F2-DWC-14)	FFFL035
Florida Request for Wage Loss/Temporary Partial Benefits (DFS-F2-DWC-3)	FFFL015
Florida Revocation of Election of Coverage (DWC 251-R)	FFFL205
Florida Revocation of Election to be Exempt (DWC 250-R)	FFFL195
Florida Sample Self-Insurers Irrevocable Letter of Credit (SI-6)	FFFL115
Florida Secure Socket Layer (SSL)/File Transfer Protocol (FTP) Instructions (10/1/2006)	FFFL360
Florida Self-Insurance Unit Statistical Report (New Applicant) [SI-17NA]	FFFL130
Florida Self-Insurance Unit Statistical Report (SI-17)	FFFL125
Florida Self-Insurers Payroll Report (SI-5)	FFFL110
Florida Self-Insurers Surety Bond (SI-4b)	FFFL105
Florida Service Company Annual Report Form	FFFL150
Florida Service Company Application (SI-22)	FFFL145
Florida Statement of Charges for Drugs And Medical Supplies Form and Instructions (DFS-F5-DWC-10)	FFFL240
Florida Statement of Quarterly Earnings for Supplemental Income Benefits	FFFL060
Florida Surety Bond (SI-4)	FFFL100
Florida Uniform Commercial Code Financing Statement (UCC-1)	FFFL175
Florida Wage statement (DFS-F2-DWC-1a)	FFFL010
Florida Workers' Compensation Uniform Medical Treatment/Status Report Form (DFS-F5-DWC-25)	FFFL215

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