Free DFS-F2-DWC-33 - Florida

PERMANENT TOTAL OFF-SET WORKSHEET

SENT TO DIVISION DATE

DIVISION RECEIVED DATE

FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION
200 East Gaines Street TALLAHASSEE, FLORIDA 32399-4224
SOCIAL SECURITY #: EMPLOYEE NAME: (First, Middle, Last) DATE OF ACCIDENT: (Month-Day-Year)

DATE OF BIRTH:

(Month-Day-Year)

EMPLOYER NAME:

DATE ACCEPTED/ADJUDICATED PT:
(Month-Day-Year)

FORMULA: 1. 2. 3. Convert monthly benefits to weekly benefits by dividing the monthly amount by 4.3. Add Compensation Rate + Primary Insurance Amount (PIA) or the Maximum Family Benefits (MFB) if the employee has dependents. Add five percent (5%) permanent total supplemental benefits for dates of accident prior to October 1, 2003. For dates of accident on or after October 1, 2003, add three percent (3%) permanent total supplemental benefits. Use Weekly Supplemental Rate at time of PT acceptance. 4. 5. Subtract the greater of 80% Average Weekly Wage (AWW) or 80% Weekly Average Current Earnings (ACE). Resulting difference is the offset amount (which shall not exceed the Initial Social Security Benefit).

BENEFITS INFORMATION (Monthly/Weekly) Weekly Compensation Average Weekly Wage Monthly PIA Monthly ACE Maximum Family Benefit __________________________ __________________________ _________________________ _________________________ __________________________ multiplied by .80 = 80% AWW divided by 4.3 = Weekly PIA divided by 4.3 = Weekly ACE divided by 4.3 = Weekly MFB _______________________ _______________________ _______________________ _______________________

Offset Calculation _______________________________ [+] [+] [=] [- ] _______________________________ _______________________________ _______________________________ _______________________________ Weekly Compensation (or applicable Maximum rate ) Weekly PIA or MFB (whichever is applicable) 5% PT Supplemental (3% for injuries occurring on or after October 1, 2003) Combined Weekly Benefits Greater of 80% AWW or 80% Weekly ACE

[a] [b] [c] [d]

______________________________ ______________________________ ______________________________ ______________________________

Total Offset Available (shall not exceed applicable PIA or MFB) weekly compensation Offset Against Supplements (Division paid claims only) Offset Against Compensation Total Benefits Payable After Offset (Comp Rate-c=d)

Effective _____________________ the Division / Claims-handling entity in accordance with Section 440.15(9) F.S., will begin applying the Social Security Offset to this case. Please attach a copy of the completed Form DFS-F2-DWC-14, Request for Social Security Disability Benefit Information and Form DFS-F2-DWC-4, Notice of Action/Change, as required by Rule 69L-3.0091, 69L-3.0194 and 69L-3.01945, F.A.C.
Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information commits insurance fraud, punishable as provided in s. 817.234. Section 440.105(7), F.S. INSURER CODE # ADJUSTER NAME INSURER NAME:

CLAIMS-HANDLING ENTITY NAME, ADDRESS AND TELEPHONE SERVICE CO/TPA CODE # CLAIMS-HANDLING ENTITY FILE #

Form DFS-F2-DWC-33 (03/2009)

Rule 69L-3.025, F.A.C.

DWC-33 Purpose and Use Statement The collection of the social security number on this form is imperative for the Division of Workers' Compensation's performance of its duties and responsibilities as prescribed by law. The social security number will be used as a unique identifier in Division of Workers' Compensation database systems for individuals who have claimed benefits under Chapter 440, Florida Statutes. It will also be used to identify information and documents in those database systems regarding individuals who have claimed benefits under Chapter 440, Florida Statutes, for internal agency tracking purposes and for purposes of responding to both public records requests and subpoenas that require production of specified documents. The social security number may also be used for any other purpose specifically required or authorized by state or federal law.