Florida Regulations 69L-3.018

• Amendments effective 1-10-05

(1) Employee's Responsibilities. During any 2 week period in which wage loss due to permanent impairment is suffered, the employee shall file a Form DFS-F2- DWC-3, as adopted in Rule 69L- 3.025, F.A.C., with the claims-handling entity within 14 days of the end of that period. The employee shall complete the "Employee" portion of the Form DFS-F2-DWC-3 and the employee shall also fill out the back of the Form DFS-F2-DWC-3 thereby furnishing the claims-handling entity a "work search report" for the period during which wage loss benefits are claimed, including the name, address, telephone number, and person contacted at each business where the claimant applied for work during the period for which wage loss benefits are being claimed, the date the claimant applied for work at each business, and a description of the type of work or the specific job for which the claimant applied at each. The listing should also include any contacts with a public or private employment agency and the dates of such contacts. The employee shall sign and date the form with the signature authorizing the release of social security information and Unemployment Compensation wage and benefits information. The employee shall send the completed Form DFS-F2- DWC-3 to the claims-handling entity. A Form DFS-F2-DWC-3 without an original signature of the injured employee shall not be processed for payment by the claims-handling entity.

(2) Claims-handling entity's Responsibilities.

(a) Within 5 working days of its first knowledge of the date of maximum medical improvement, the claims-handling entity shall send to the employee an informational letter which explains the employee's possible eligibility for wage loss benefits, together with at least 4 copies of the Form DFS-F2-DWC-3. The letter to the employee must contain at least the following: "Your treating physician has reported that you have reached maximum medical improvement and you may return to work but that you have a permanent impairment which has resulted in a work-related physical restriction which may affect your ability to perform the duties of your usual occupation or other appropriate employment. If this physical restriction causes you to lose wages, you may be entitled to additional benefit payments under the Florida Workers' Compensation Law. If you lose wages, you must complete and send a REQUEST FOR WAGE LOSS/TEMPORARY PARTIAL BENEFITS Form (DFS-F2-DWC-3) to us within 14 days after the end of any 2 week period for which a loss of wages is claimed. If you fail to send the completed form within that 14 day period, you may be ineligible for wage loss benefits during that period. In addition, to be eligible for wage loss benefits, you must demonstrate that you have made a valid effort to obtain suitable gainful employment and that your loss of wages is due to your work-related physical restriction and NOT due to economic conditions, the unavailability of jobs, your unemployment due to misconduct or your failure to accept employment within your capabilities. To show that you have made a genuine effort to obtain employment, list the dates, names, addresses, type of work, person contacted and the telephone number of the places of employment that you have contacted on the reverse side of the REQUEST FOR WAGE LOSS/TEMPORARY PARTIAL BENEFITS form. You should also list the dates you make contact with any public or private employment agency. Please note that the Florida Workers' Compensation Law allows us to evaluate your efforts to obtain gainful employment beginning with the 13th week after you have reached maximum medical improvement. If it can be shown that there are actual job openings within your geographical area and which are within your physical and vocational capabilities, the amount of earning you could have earned at those jobs can be deducted from your benefit payment. Enclosed are REQUEST FOR WAGE LOSS/TEMPORARY PARTIAL BENEFITS forms for your use. Keep them with your other valuable documents until you either use them or your entitlement to these benefits expires. We are also reporting your permanent impairment to the Division of Workers' Compensation in Tallahassee. If you desire further information regarding wage loss benefits, you may call the Employee Assistance and Ombudsman Office of the Division of Workers' Compensation at any of their local offices, or at 1(800)342- 1741." (b) The claims-handling entity shall date stamp the Form DFS-F2-DWC-3 upon receipt and within 14 days of receipt of the Form DFS-F2-DWC-3 from the employee, the claims-handling entity shall complete calculation of benefits due, make any payments due, and send copies of the completed form to the employee and the employer. The claims-handling entity shall also send the employee a blank Form DFS-F2-DWC-3. If the claimshandling entity is denying wage loss benefits, the claims-handling entity shall indicate in the claims-handling entity processing section of the Form DFS-F2-DWC-3 that wage loss benefits are being denied, complete a Form DFS-F2-DWC-12, as adopted in Rule 69L- 3.025, F.A.C., and send both forms to the employee, employer, legal counsel, and the Division within 14 days of the claims-handling entity's receipt of Form DFS-F2- DWC-3.

(3) Calculation of Wage Loss Benefits. The first calendar week of eligibility for wage loss benefits may be a partial week since eligibility begins on the date of maximum medical improvement. All other weeks of eligibility shall be full calendar weeks. To determine the amount of wage loss benefits due for a partial week: divide the pre-injury average weekly wage by the number of days employed per week, multiply by the number of days from date of maximum medical improvement through the last working day of that calendar week, multiply by 85% if the date of accident is before July 1, 1990 or by 80% if the date of accident is July 1, 1990 or later, insert the resulting figure on the DFS-F2- DWC-3 in the box labeled "ADJ. WW", and complete the calculations shown on that form.

Specific Authority 440.15(3)(b), 440.185(4), (10), 440.41, 440.591 FS. (1993) Law Implemented 440.15(3), 440.185(4), (10) FS. History-New 10-30-79, Amended 11-5-81, 5-30-82, 6-12-84, Formerly 38F-3.18, Amended 4-11-90, 1-30-91, 11-8-94, 11-11-96, Formerly 38F-3.018, 4L-3.018, Amended 1-10-05.