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Florida Worker's Compensation Forms


To view a listing of the forms by category, click on a link below. To search for a specific form by name or keyword, use the "Find on This Page" feature of your browser.

 

 

Intakes and Case Information

Intakes and Case Information
Attorney Intake
Doctor Intake
Hospital Intake
New Case Information Form
New Case Information Form

Accident Reporting

First Report of Injury or Illness (LES Form DWC-1)

Appeals

Notice of Estimated Cost of Preparation of Record on Appeal (Form 4.912)

Financial Affidavit in Support of Verified Petition for Relief From Costs (Form 4.9125)

Financial Affidavit (LES Form AFSU-10)

 

Attorney's Fees

Motion for Ex Parte Payment of Attorney Fee and Costs (Form 4.905)
Order Approving Attorney Fee and Costs (Form 4.906)

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Attorney Representation

Contract of Representation, Power of Attorney, Trust Agreement, and Motion (Form 4.903(a))

Contract of Representation, Power of Attorney, Trust Agreement, and Motion (Form 4.903(b))

Contract of Representation, Power of Attorney, Trust Agreement, and Motion (Form 4.903(c))

Order Approving Contract of Representation and Directing Payment of Benefits (Form 4.904)

Order on Motion to Withdraw as Counsel (Form 4.907)

 

Benefit Request

Mileage Request Form (MRF-1)

Request for Assistance (EAO-1)

Request for Wage Loss/Temporary Partial Benefits (LES Form DWC-3)

Petition for Benefits/Docketing Order (PFB-B94W)

Claim Status

Notice of Action/Change (LES Form DWC-4)

Maximum Medical Improvement/Permanent Impairment Determination Certification Form (LES Form DWC-9a)

Instructions for Completing Maximum Medical Improvement/Permanent Impairment Determination 

Statement of Charges for Drugs and Medical Supplies (LES Form DWC-10)

Instructions for Completing Statement of Charges for Drugs and Medical Supplies

Notice of Denial (LES Form DWC-12)

Claim Cost Report (LES Form DWC-13)

 

Coverage Compliance

Proof of Coverage (LES Form BCM-240)
Proof of Coverage Attachment (LES Form BCM-240-A)
Endorsement (LES Form BCM-241)
Endorsement Attachment (LES Form BCM-241-A)
Notice of Cancellation or Reinstatement (LES Form BCM-242)
Bureau of Compensation Web Site Referral Form (NCRF-1)

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Coverage Exemptions

Notice of Election to Be Exempt (LES Form BCM-250)

Instructions for Completing Construction Industry Application for Exemption

Instructions for Completing Non-Construction Industry Application for Exemption

Revocation of Election to Be Exempt (LES Form BCM-250-R)

Notice of Election of Coverage (LES Form BCM-251)

Revocation of Election of Coverage (LES Form BCM-251-R)

 

Data Reporting

Monthly Risk Class/SIC Code Report (LES Form DWC-48)

Aggregate Claims Administration Change Report (LES Form DWC-49)

Aggregate Defense Attorney Fee Report (LES Form DWC-51)

 

Health Care

Notification of Initial Treatment (LES Form DWC-8)

Instructions for Completing Notification of Initial Treatment

Explanation of Benefits (LES Form SDF-6)

 

Hearing Request

Petition for Benefits (Form 4.9075) 

Application for Expedited Hearing (Form 4.9091)

Mediation

Notice of Mediation Conference and Order (Form 4.9085)

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Motion Practice and Subpoena

Caption and Style of Pleadings (Form 4.901)

Attorney's Certificate of Service of Ex Parte Order (Form 4.902)

Certificate of Notary Public (Form 4.9105)

Subpoena for Deposition for Issuance by Judge of Compensation Claims (Form 4.913(a))

Subpoena for Deposition for Issuance by Attorney of Record (Form 4.913(b))

Subpoena Duces Tecum for Deposition for Issuance by Judge of Compensation Claims (Form 4.913(c))

Subpoena Duces Tecum for Deposition for Issuance by Attorney of Record (Form 4.913(d))

Subpoena Duces Tecum Issued by Attorney of Record for Witness to Produce Records (Form 4.913(e))

Subpoena for Trial for Issuance by Judge of Compensation Claims (Form 4.913(f))

Subpoena for Trial for Issuance by Attorney of Record (Form 4.913(g))

Affidavit of Service of Subpoena (Form 4.9135)

 

Physician Certification

Health Care Provider Application for Certification (LES Form DWC-97)

Expert Medical Advisor Application and Contract for Certification (LES Form DWC-98)

Instructions for Completion of LES Forms DWC-90, DWC-97, DWC-98

 

Pretrial

Uniform Pretrial Stipulation and Pretrial Compliance Questionnaire (Form 4.910(a))

Uniform Pretrial Stipulation and Pretrial Compliance Questionnaire (Form 4.910(b))

Uniform Pretrial Stipulation and Order for Penalty Cases (Form 4.916)

 

PTD Worksheets

Permanent Total Off-Set Worksheet (LES Form DWC-33)

Permanent Total Supplemental Worksheet (LES Form DWC-35)

Rehabilitation

Individualized Written Reemployment Plan (LES Form DWC-20)

Reemployment Services Reporting Form (LES Form DWC-21)

Instructions for Completing Reemployment Services Reporting Form 

Reemployment and Annual Case Status Review Form (LES Form DWC-22)

Instructions for Completing Reemployment and Annual Case Status Review Form 

Alternate Carrier Reemployment Services Activity Report (LES Form DWC-22a)

Instructions - Alternate Carrier Reemployment Services Activity Report

Request for Screening (LES Form DWC-23)

Instructions for Completing Request for Screening 

Agency and Student Agreement for Sponsorship of Retraining (LES Form DWC-24)

Qualified Rehabilitation Provider (LES Form DWC-96)

Instructions for Completing Qualified Rehabilitation Provider Application 

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Self-Insurers

Application for Self-Insurance (LES Form SI-1)

Re-Application for Self-Insurance (LES Form SI-1a)

Surety Bond (LES Form SI-4)

Self-Insurers Surety Bond (LES Form SI-4b)

Self-Insurers Payroll Report (LES Form SI-5)

Sample Self-Insurers Irrevocable Letter of Credit (LES Form SI-6)

Indemnity Agreement (LES Form SI-11)

Self-Insurance Unit Statistical Report (LES Form SI-17)

Self-Insurance Unit Statistical Report (New Applicant) (LES Form SI-17NA)

Report of Outstanding Workers' Compensation Liabilities (LES Form SI-20)

Sample (Held by Bank or Savings & Loan) Assignment of Securities (LES Form SI-32)

Certificate of Self Insurance (LES Form SI-206)

 

Settlement

Orders Approving Settlement of Prospective Benefits (Form 4.911(a))

Orders Approving Settlement of Prospective Benefits (Form 4.911(b))

Orders Approving Settlement of Prospective Benefits (Form 4.911(c))

Orders Approving Settlement of Prospective Benefits (Form 4.911(d))

 

Special Disability Trust Fund

Proof of Claim for Submission to Special Disability Trust Fund (Form 4.914)

Uniform Special Disability Trust Fund Pretrial Stipulation (Form 4.915)

Preferred Worker Reimbursement Request (LES Form PW-2)

Proof of Claim (LES Form SDF-1)

Reimbursement Request (LES Form SDF-2)

 

Third Party Administrator

Certification of Servicing for Self-Insurers (LES Form SI-19)

Service Company Application (LES Form SI-22)

Service Company Annual Report Form (LES Form SI-23)

Actuarial Report Checklist (LES Form SI-26)

Biographical Statement and Affidavit (LES Form SI-27)

 

Trial

Notice of Hearing, Other Than Final Hearing and Pretrial Conference (Form 4.908)

Notice of Final Hearing and Pretrial Conference (Form 4.909)

Notice of Expedited Hearing and Order (Form 4.9092)

 

Wage & Earnings

Wage Statement (LES Form DWC-1a)

Request for Social Security Disability Benefit Information (LES Form DWC-14)

Employee Earnings Report (LES Form DWC-19)

Authorization and Request for Unemployment (LES Form DWC-30)

Statement of Quarterly Earnings for Supplemental Income Benefits (LES Form DWC-40)

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