There are many workers' compensation claim forms you will encounter if you get injured at work. While many of the forms may seem confusing, there are four main workers' compensation claim forms you should become familiar with.
These are:
- First Report of Injury or Illness (DWC-1);
- Wage Statement (DWC-1a);
- Employee Earnings Report (DWC-19); and
- Florida Workers' Compensation Uniform Medical Treatment/Status Reporting form (DWC-25).
These forms, and more Workers' Compensation claim forms can be found at the Florida Workers' Compensation website at www.fldfs.com.
This is the first claim form that should be filled out after you have been injured on the job. This workers' compensation claim form is supposed to be filled out by your employer, and signed by both you and the employer. The First Report of Injury form contains all the factual information about the employer, your employment, and the basic information surrounding your accident and injury.
It is critical that this workers' compensation claim form be filled out immediately after your accident occurs. This form is sent to the employers workers' compensation insurance company, and it allows the insurance company to set up your claim so that you can begin receiving medical care and wage benefits.
Many times during your workers' compensation claim you may hear people refer to your "AWW". The "AWW" refers to your average weekly wage, which is calculating by averaging your weekly wages during the 13 week period immediately proceeding your date of accident. The workers' compensation claim form used to calculate your "AWW" is the Wage Statement. Your wages are to be calculated using the 13 calendar weeks preceding your date of accident. A calendar week is defined as a 7 day period of time which starts on Sunday and continues through Saturday. Wages earned during the week of the accident are not to be calculated in the average weekly wage. Additionally, the employer is supposed to include the employers costs of any fringe benefits such as health insurance or housing that is provided.
When you are injured on the job, and your workers compensation doctor says you are unable to return to work, you may be entitled to temporary partial disability or temporary total disability wage payments. Temporary total disability payments equal 66⅔% of your average weekly wage. Temporary Partial Disability payments are slightly less and depend on the amount of income you may be earning while you are still receiving medical care.
A workers' compensation insurance company can require you to fill out the Employee Earnings Report on a monthly basis so that they can determine the amount of wages you are earning while you are receiving workers' compensation benefits. The Employee Earnings Report asks for wage information from any jobs you may have, in addition to, income you may be receiving from Social Security, unemployment compensation or any short term or long term disability policy. Failing or refusing to fill out this worker's compensation form may allow the insurance company to stop your wage benefits until the form is completed accurately and returned to the workers' compensation insurance company.
Reporting Form (dwc-25)
This workers' compensation claim form is used by your treating physicians, and a copy of this should be given to you after every doctors visit. There are many important questions on this form which the doctor needs to address, and which affect the type of medical and wage benefits you may receive. This workers' compensation claim form will address:
- Whether your injury is related to your work accident;
- Whether there is some pre-existing condition which contributed to your current medical condition;
- Whether you need a referral to a specialist, additional physical therapy, diagnostic testing such as an MRI or CT Scan, whether you need medication, or whether you are a candidate for some type of surgery;
- What your physical limitations are while you are receiving workers' compensation care, i.e. are you on "light duty" work status;
- Whether you have reached Maximum Medical Improvement and if so, what your Impairment Rating is; and 6. The date of your next doctor's appointment.
The doctor's office should provide you with one of these forms after it has been filled out by the doctor, every time you visit the doctor. It is important to provide this workers' compensation claim form to your attorney, or to your insurance adjuster, so that any medical or wage benefits which the doctor is recommending can be obtained as soon as possible.
The workers' compensation claim forms summarized above are just a few of the many forms you will encounter if you become injured on the job. To get more information about these forms, and forms necessary to successfully pursue your workers' compensation claim, please contact attorney Joseph M. Maus or call us at 1-866-556-5529 for a free consultation.
