This form is used to initially report an injury or illness that occurred during the course and scope of employment to the Department of Financial Services Division of Workers’ Compensation. The document asks for all pertinent and relevant details for the individual who was injured. The form is to be completed in print or typed for ease of legibility. If, at any point, assistance is needed to complete, or any questions are had regarding the completing of this form, you should contact your local EAO office or call the toll-free number provided on the form, 1-800-342-1741.
You don’t need to fill out the top portion of the file; only the department’s personnel fills out that section.
Along with the employee’s contact information, the form asks for the disclosure of the employee’s social security number. Giving the department the social security number allows them to process the employee through the regulated systems according to Florida state Laws when making a workers’ compensation claim.
Description of the Accident – Write a detailed description of the accident or illness. Outline from beginning to end what happened. To be sure that the entire accident is captured from beginning to end, describe your steps leading up the accident, what happened during the accident, and what happened immediately after the accident occurred.
Injury/Illness that Occurred – This information can be taken from the medical records diagnoses section. Usually, the physician will put a medical code alongside the name of the injury or illness.
Part of the Body Affected – Be sure to also be specific when stating which body part was affected. For example, instead of saying knee, state which knee was affected.
Be sure to list the information as clearly and specifically as you possibly can as you want to be sure that the department investigates the proper employer and can get to the right department within your employer’s company to not further delay your claim.
Complete by signing the form to certify that you have read and completed the form with information that is true and correct. The employer will also sign this document. Once both parties have signed, this document will be forward to the department with a wage statement (DWC-1a). The wage statement is a form that details your wages. This document is to be completed by the employer.
This form is essential to the claim. Without this form being properly executed and attached to DWC-1, the worker’s compensation claim be suspended until the error is rectified with the completed document.