MCIM Claim Forms - Florida
DWC-1 First Report of Injury
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NOTE: Adobe Acrobat Approval, Standard, or Professional version 5 or newer is required for viewing this form.
| DWC-1 |
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.
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.
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.
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.
Important Information for Florida Employers
Información Importante para los Empleadores de la Florida
Información Importante para los Empleadores de la Florida
Important Employee Information for Florida Workers
Información Importante para los Trabajadores de la Florida
Información Importante para los Trabajadores de la Florida
