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MCIM Claim Forms - Florida

DWC-1 First Report of Injury
NOTE: Adobe Acrobat Approval, Standard, or Professional version 5 or newer is required for viewing this form.
DWC-1
File Size: 153 kb
File Type: pdf
Download File

Use: Reporting claims by Employer to Carrier.

Filing Requirements:
Employer: Reporting all cases, except 1st aid cases to the carrier within 7 days of knowledge of the injury or accident. If the first aid claim becomes a medical only or lost time claim, then the employer shall report within 7 days of knowledge. The information on the form may be called in or faxed in to the carrier. The form should not be delayed because the employee signature is not available.

Statutory or Rule governing: 69L – 3.004, 3.0045.
Comments: the division assesses penalties if the form is not filed timely in all cases. Penalties are days 1-7 $100.00, days 8-14 $200.00, days 5-21 $300.00, days 22-28 $400.00; & 28 days & over are $500.00. Issues can be responded to in letter form to the division asking for ‘reconsideration of the penalty’ with a detailed explanation of why the NOI was not timely.

DWC-1a Wage Statement
Please follow the attached instructions when completing the DWC1a.

Mileage Reimbursement  
Petición de Reembolso del Kilometraje
This form is included for the worker’s convenience in requesting reimbursement for mileage incurred traveling to medical appointments in connection with the injury. Injured Worker’s can submit thoroughly completed forms to their examiner.

Employee Questionnaire
Cuestionario al Empleado
Initial Form to be completed by the injured worker.

Witness Statement
Form to be completed by a witness to the accident.

Medical Authorization    
Autorización Médica

Authorization to obtain medical information.

Important Information for Florida Employers    
Información Importante para los Empleadores de la Florida

Important Employee Information for Florida Workers    
Información Importante para los Trabajadores de la Florida

False or Fraudulent Claim Statement    
Informe de Reclamo Falso o Fraudulento

Notice of Compliance (Broken Arm Poster)    
Aviso de la Conformidad

Anti-Fraud Reward Program

Join the Battle Against Workers’ Compensation Fraud  

Accident Investigation Report    

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  • Home
  • About MCIM
    • Products & Services
    • News
    • Careers
  • Claims
    • Report an Injury
    • Return to Work Program
    • The Value of Early Reporting
    • Florida Claims Forms
    • Georgia Claims Forms
    • Illinois Claims Forms
    • Indiana Claims Forms
    • Michigan Claims Forms
    • Wisconsin Claims Forms
  • Loss Prevention
    • Safety Inspections
    • Safety Resources
    • Safety Training Videos
    • Safety Training Programs
  • Bill Pay
  • Agencies
  • Contact Us
  • My MCIM
    • Newsletters