Scribd
Upload
31 views

DWC12

Uploaded by

Nader chazli
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
31 views

DWC12

Uploaded by

Nader chazli
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

SENT TO DIVISION DIVISION

NOTICE OF DENIAL DATE RECEIVED DATE


FLORIDA DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS’ COMPENSATION
200 East Gaines Street
Tallahassee, Florida 32399-4226
COMPLETE ALL APPLICABLE SECTIONS BEFORE FILING WITH THE DIVISION

PLEASE PRINT OR TYPE


SOCIAL SECURITY NUMBER EMPLOYEE NAME (First, Middle, Last) DATE OF ACCIDENT: (Month-Day-Year)
445-75-6652 Timoteo Perez 12/09/2022
EMPLOYEE ADDRESS EMPLOYER NAME
2800 Georgia Ave HAYNES SCAFFOLDING & SUPPLY INC.
West Palm Beach, FL 33405
ATTACH ADDITIONAL PAGE(S) IF NECESSARY
DENIED BENEFITS (List below)
All benefits

REASON FOR DENIAL OF BENEFITS (Provide detailed information to support reason(s) for denial)
Idiopathic personal in nature not work related

DATE DENIAL RESCINDED: _____ / ____ / _______ Description of benefits reinstated or started:

CC: (Name and Address)

ADJUSTER NAME ADJUSTER TELEPHONE


LARRY JACKSON ( 407-660-5600- ________________ Ext. _______
) __________
INSURER CODE DATE PREPARED INSURER NAME
03/06/2023 CoAction/New York Marine
CLAIMS-HANDLING ENTITY NAME AND ADDRESS
SVC. CO/TPA CODE CLAIMS-HANDLING ENTITY FILE CCMSI
# 22P05K512618
2600 Lake Lucien Dr., Suite 225
MAITLAND, FL 32751
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.
Form DFS-F2-DWC-12 (03/2009) RULE 69L-3.025, F.A.C.
DWC-12 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.

You might also like