C-20077EE-CVR New 1-00 Printed in U.S.A.

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1 Employee: Employer: Date File Social Number: of Security Injury: We are your employer's No.: informational regulations. If have attached your copy workers' of the compensation Notice of Injury, insurance as well as carrier. Sincerely, you have any Please purposes questions, retain and all please does copies not call for necessarily me. your records. have the full literature, effect of law which and/or is for C-20077EE-CVR New 1-00 Printed in U.S.A.

2 C20077EE#1 receive Compensation This pamphlet gives ABOUT general WHAT WORKERS' information EMPLOYEES about INTRODUCTION COMPENSATION the Florida NEED Workers' TO Compensation KNOW Employee IN FLORIDA attached Please If you information page. have Assistance any can (TDD questions help about Office you your at through about this rights, toll-free workers' the / benefits Voice process number: ) compensation, and so responsibilities , you can please return You call to work call the will Division any also as quickly of learn the of field how Workers' as possible. offices the Program. Division Compensation listed You of on will Workers' insurance "Any be advised person company that: who knowingly self-insured and program with intent or to who injure, files defraud a statement deceive of claim any containing employer, any employee, false an It This misleading your coverage responsibility information will pay for to BASIC commits report the most FACTS a work-related is reasonable a paid felony by ABOUT of your and accident the employer third necessary WORKERS' as degree." soon at medical no as cost COMPENSATION it happens. to care you. if get hurt or sick because or has after * Your Workers' injury employer on Compensation your job. or its workers' coverage compensation will also replace insurance part carrier of your has lost wages right if your choose doctor the says doctor you who must will treat of out an may be The for more you a intent certain reach than of 50 maximum the length employees, law of is time to medical ensure your because improvement employer that of you a work-related return should (MMI). to make work If injury a as good soon or illness. faith as the effort does doctor not return says make you a good to are work able. faith within If effort your your to workplace do restrictions this, of you. (EAO) posted have to at pay your a worksite. fine. Your If employer's not ask your workers' supervisor compensation for your employer's insurance carrier's or call name the and Employee telephone Assistance number Office should work work, You of should Division know of that Workers' if you Compensation are caught reporting ( ) a work-related the injury closest when EAO you field know office you listed were not attached injured it Follow you these could simple be convicted rules: HOW of a felony TO GET of the MEDICAL third degree. CARE AND BENEFITS page. Report Go to your doctor job-related chosen injury by your or illness employer to your your supervisor employer's as soon workers' as possible. compensation insurance carrier. at either employer Illness. complete carrier, For by you To telephone forms keep to the begin receiving when workers' getting asked. by compensation completing benefits benefits, If you during have your a First insurance any the employer Report time questions carrier of must Injury are about report must unable those Illness. provide the to forms injury You you (or to that should a its working copy are workers' not complete of your answered a compensation reduced First all forms Report by salary), your when of insurance employer Injury you asked. must or carrier If Be sure please you call do or call the everything Employee any of the possible EAO Assistance field to cooperate offices Office listed (EAO) with on your at the employer attached Division page. and of Workers' its workers' Compensation compensation for assistance insurance carrier. at Your you Complete Keep do all not, appointments. all your workers' compensation may stop be forms delayed. in a timely Be sure manner. you: or Report Get compensation approval any earnings from benefits) the to insurance the that workers' you carrier get compensation after before your injury. receiving insurance treatment. carrier If (including you are social satisfied security with and the doctor unemployment made * Be Return Keep assigned, or aware necessary all to records that work ask your as medical soon right a workers' safe as to care place the receive compensation provided doctor for benefits future says for reference. a and insurance one can. medical year period. carrier care may to approve end if there another has doctor. been no payment for lost first wages

3 C20077EE#2 MEDICAL injury Workers' Compensation BENEFITSWHAT insurance TYPES pays for all OF reasonable BENEFITS and necessary CAN medical YOU GET? Visits Surgery Hospital Dental Prescription illness to care an care approved including: drugshealth care provider (chiropractic visits may be limited) care related to your on-the-job You without receive the for * Before Braces Other medical being and crutches treated, supplies be when sure you ordered have by the your approval approved of your physician. carrier, bill are to approved the not your workers' responsible carrier. treatment, compensation There for the is one doctor insurance exception. bills will as bill carrier's long If the you workers' as were the approval, carrier injured compensation employer's approves you on or will after probably insurance the workers' January doctor be compensation carrier 1, you responsible 1994, are directly. seeing. your for insurance doctor If the If you bill. is are see responsible When carrier. billed, a doctor PAYMENT collecting but need there directly copies may from of be any a you charge medical a $10 for co-payment reports, these copies. you per can visit get after them you from reach your maximum doctor or workers' medical improvement compensation (MMI). insurance you If your earnings FOR are LOST lower WAGES of a work-related injury or illness, you may be able to receive some cash benefits send (indemnity days on are the benefits). unable advise to of work to You your return but may approved to because work eligible as doctor of a your for result and these injury of one the benefits you of accident. the earn if following you wages have less is been true: than out 80% of work of what for you more earned than seven before (7) your calendar These if * These Your permanent cash doctor payments benefits impairment.) says can begin help will on you have the eighth through a permanent day the of period partial loss of or a time total bodily you disability. function are disabled You as a will result from be your paid of your workplace for injury. the first (This injury seven is called (7) illness. days injury. send weeks and Call listed you To your the are help immediately workers' disabled the workers' compensation before more compensation you than were insurance twenty-one benefits. injured. insurance If carrier The you (21) carrier have days. and a you These will second calculate a use report days this job, the do information of your benefits your not average have wages that to weekly be are calculate and continous due, certain wage your fringe may calendar employer average include benefits days. weekly is both required for the wage incomes. only REEMPLOYMENT the on Employee an attached Assistance page) SERVICES or Office your employer's of the Division workers' of Workers' compensation Compensation insurance carrier for more (or details. any EAO field office 13 to may The * If, Vocational Help types qualify as a of result writing finding to services testing receive of resumes a your job you and reemployment work may counseling injury receive or services. to will illness, help vary identify you The depending cannot goal employment of earn these upon wages the services options date similar is you to to were help those you injured you return earned or became to work before ill. as They soon your injury, may as you include: you For Training more and information education about if needed reemployment for you to services, be able to please return contact to work the Rehabilitation and Medical Services Officescan. closest PREFERRED you employer (phone If To may you find to numbers have that you. out eligible come if a There you permanent WORKER are to from qualify listed is receive a listing hiring on for disability PROGRAM an a of you. Preferred attached these This and ofices may are page). Worker unable at make the Card. Card, it end to easier return The call of this card the for to booklet. Rehabilitation your will to tell regular get a future a job. and employer because Medical of about Services a workplace financial Office injury benefits closest or for to illness, you the

4 your office This ELIGIBLEAfter BENEFITTEMPORARY TYPE TYPES OF BENEFIT PAYMENTS WHEN employer's table listed OFsummarizes on DISABILITY an workers' attached TOTALthe (TTD)TEMPORARY compensation page) types TOTAL to of learn AT payments DISABILITY 80% carrier more or about you DISABILITY the TEMPORARY may PARTIAL Employee the benefits receive (TPD)IMPAIRMENT Assistance you if you may INCOME are receive. Office injured of the on SUPPLEMENTALREHABILITATION or Division after January of Workers' 1, TTD & EDUCATION Compensation (TRAINING) If you have at DISABILITY been PERMANENT TOTAL injured (PTD)DEATH before (or any that EAO date, BENEFITS field call BECOME YOUdisability 7 days ofafter disability 7 days ofafter disability 7 days ofafter assigns impairment your andoctor ratingafter income your benefits impairment endafter been by to a education program training participate the you approved Division have andin After you defined your below an doctor injury says asafter person workers' compensation and dependency defined you the eligible by can death law show asof fora CONDITIONS ELIGIBILITYDoctor FORcannot says work you at all* * Doctor Loss Paraplegic, Blindness cannot hand paraparetic, quadriplegic, quadriparetic of or says work arm, footyou leg, at all * Doctor You are less your wages modified able are than previous says earning to 80% return duty youofyour MMI an rating temporary disability end been impairment impairment have and doctor assigned your assigns benefits reached rating* says have an * Your You rating or good find earn of more impairment the are suitable more faith must not made effort than able be work 20% and your your required have AWW completed form80% a carrier returned employer's it to to * You The carrier Division screening determined you reemployment services Division qualify or request yourfor that hasyou and following Spinal Loss Severe Second causing or injury have are foot of unable cord brain arm, conditions: one paralysis injury of leg, or to thead work over third 25% of handif a result * Blindness A body burns and qualify Security Benefits condition hands or to you third Disability 5% for that of degree Social face would yourof accident * death or years if was disability the injured workplace on of of and accodent continuous within accident person one five PAYMENT2/3 PAYMENT104 AMOUNT OF weekly (AWW) maximum of average wage up to a80% to of a $700 maximum of AWW up Calculated formulabyone your weekly benefits a maximum half average TTD up (1/2) toofcalculated by formula2/3 up to of a your maximum2/3 AWWmaximum of your AWW up to aif dependency may * Benefits Funeral Other a by up benefits relative formula to $5000 available eligible expenses calculated can he/she show LONG HOW for: RECEIVE CAN YOUuntil releases modified work have maximum improvement (MMI) TTD weeks your AND or reached says you duty doctor TPD medical or you COMBINED Up from accident to the six CANNOT date months ofexceed 104 your MMIweeks have doctor 104 WEEKS reached or says untilfor percentage of impairment you weeks your each will of permanent receive benefitsuntil point rating, 3401 passed of accident weeks a maximum since have the date of an 26 approved weeks extension with if of Until you are reemployeduntil $100,000 paid; certain a there total exceptions. has are ofbeen C20077EE#3

5 RETURN However, return Can You my should TO employer WORK not be fired QUESTIONS me in if retaliation I am out QUESTIONS and for filing receiving or attempting workers' AND ANSWERS compensation to file a workers' benefits? improvement as Q. A. soon Must No. to as work. the Your possible. I be workers' (MMI). doctor released The compensation may law to release full is written duty you before law so does that modifed I can it not is return beneficial require or light to your work? duty to both employer work you before and to hold your your have employer compensation position reached for for you maximum claim. you to return until medical you to work can INSURANCE coverage. Is my QUESTIONS BENEFIT Employers Do No. I An Your have employer employer to with pay required four for in pays the coverage or more construction to the have premium. employees, under workers' industry this Your insurance? part-time compensation employer with one or full-time, cannot or insurance? more require are employees required you to is to pay required have any workers' part to have of the compensation insurance. self-insured. Where It comes PAYMENT does from my your workers' employer's QUESTIONS compensation workers' benefit compensation check come insurance from? carrier or from your employer if premium. Are No. Can workers' my benefits compensation lowered benefits for failure taxable? to use safety appliances or follow safety rules? it is individually report workers' after Q. using Yes, When The your safety earliest your injury will appliances cash I get immediately date my benefits you first provided can check? may to expect your by lowered employer your first employer. by and check 25% the if is your First within Report injury three occurred of weeks Accident of while your or you Illness injury. were is This completed not can following only and happen safety sent rules and A. your learning compensation doctor). will be insurance disabled for carrier more shortly than seven after that. days The (the carrier is will required gather to information send a check from within you, fourteen your employer to if days you how serious How There long your are limits can injury I collect on is, how and workers' long what you benefits compensation can receive you are benefits. receiving. benefits? These Call limits your vary workers' depending compensation upon the insurance date carrier are injured, or the the understand Workers' compensation Q. Employee What Call your can why Assistance employer's I your do if benefits I am Office not workers' have receiving of the stopped compensation Division my or benefits? of not Workers' provided, insurance Compensation call carrier the Employee first, to then, get Assistance if information are not Office specific satisfied the to or your Division do case. problems, help Claims. A. The Compensation Employee insurance Assistance at carrier Office This assistance will provide or any is of assistance the EAO free field to you of offices charge. in resolving listed If this on your office attached disagreements unsuccessful page. with in resolving your not C20077EE#4 you through the staff the will workers' assist you compensation in completing system; a Petition however, for Benefits. they cannot Please represent note, the you Employee before a Assistance Judge of Compensation Office workers' of will your

6 MEDICAL necessary treatment Q. Do Your I have employer BENEFITS to pay or any its QUESTIONS of workers' the medical compensation costs? If A. If you after care. you injured reach on maximum after January medical 1, improvement 1994, insurance are (MMI). required company to must pay a pay $10 for co-payment all approved per and visit medically to receive How All authorized a the bill, doctors mail health it to care and the other providers carrier. health Do must not care pay bill providers your it yourself. employer's paid? If you workers' know the compensation claim number insurance the carrier carrier for has medical unhappy you your Can No. case, Your I choose write employer it my on own all or bills its doctor? and workers' correspondence. compensation insurance carrier can choose the doctor to treat you. assigned If directly. anything field A. with office If Possibly. I I another think with can nearest do? I need Call doctor. you the one about Employee chosen type available of by treatment Assistance the options. carrier and Office the want workers' at the to request Division compensation a of second Workers' opinion, insurance Compensation you company must ask at disagrees, the carrier is to there you provide or are the if GENERAL When is you reach impairment maximum rating medical assigned? workers' you have How You compensation should a long permanent QUESTIONS do report I have benefits. loss the to accident report of function the immediately accident of improvement a part to of to my your your employer? (MMI), body. supervisor your treating order doctor not to must cause give a delay you an in receiving impairment any rating Workers' compensation What Call If my Compensation your employer can employer's I do if has my ( ), a employer workers' Drug Free refuses compensation Workplace to the complete Employee Program, insurance a First can Assistance carrier, Report I still get or of Office the workers' Injury Employee nearest compensation Illness you Assistance for (see my list accident benefits? on Office an attached of the illness? It Where depends; do benefits. I get if you help test if positive I think my for employer drugs or alcohol workers' at the compensation time of accident, insurance you could carrier lose is not your treating workers' me Division fairly? page). of Assistance your Call Am A lump I the field entitled sum Employee office settlement to nearest a lump-sum Assistance you. allowed settlement Office but of is the of not my Division mandatory. case? of Workers' Any negotiations Compensation are strictly voluntary between the you Employee workers' Division Q. employer's Should compensation are I not hire workers' required attorney? insurance compensation to have carrier an attorney. insurance can usually Free carrier, assistance be handled must is quickly available. be approved by calling Disputes by the a between Employee Judge of you Compensation Assistance and your Office employer's Claims. and the C20077EE#5 A. Employee attorney's You of Workers' cannot may fees. Assistance hire have Compensation attorney a Office dispute dispute to heard help resolution you by a if Judge you program. choose. of or Compensation the If Employee you do hire Claims Assistance attorney, until Office you you have nearest may participated be you. responsible in good for faith paying of the

7 earned may established Average Compensation Weekly Rate Wage (Comp (AWW): Rate CR): GLOSSARY Disability: First not by Impairment Indemnity Injury: Aid include an injured Treatment: income worker from during jobs The other wage 13 than weeks used to calculate payments for lost wages. It is the average weekly wage Maximum Medical Benefits: Rating: 66 the 2/3% one before of where the injury. average the Depending injury weekly occurred. on wage the up date to of a maximum accident, the benefit AWW may or percentage by Incapacity, the Division Treatment Modified Safety Program: or Light Duty Improvement: A due determination of to Workers' the provided injury Compensation. Work: (MMI): of an illness, injured the workplace to worker's earn the for loss same which of physical wages there are as function before no medical the as a injury. percentage. charges. This has represents Cash the extent benefits of a paid work-related to an injured injury has permanently to replace part impaired of wages the injured lost as a worker. result of a work injury. the schedule. Personal injury, illness or death by accident The point arising in time out when of and the treating the course physician of employment. believes the injured worker an recovered as much she is going to. rules Employment that within the of the injured worker as defined by Temporary active doctor. safety It Partial may include Total committee, A Disability: comprehensive a safe change working program duties practices consistent designed and procedures, with to provide the physical a employee safe capabilities, work training environment, number equipment, including of hours job but worked specific not limited safety break job duties. and personal The injured protective worker equipment. has A A disability some capability that that completely temporarily to work prevents but prevents with as changed injured injured duties worker worker from with from returning reduced performing hours. to work his/her for anormal to: temporary COCOA DAYTONA time... period.employee FT. GAINESVILLE ASSISTANCE DISTRICT OFFICES JACKSONVILLE MIAMI LAUDERDALE MEYERS. BEACH ORLANDO PANAMA.. CITY REHABILITATION AND MEDICAL SERVICES PENSACOLA TALLAHASSEE TAMPA WEST PALM BEACH DISTRICT OFFICES DAYTONA FT. GAINESVILLE JACKSONVILLE MIAMI LAUDERDALE MEYERS... BEACH PENSACOLA ORLANDO SARASOTA C20077EE#6 PAMAMA CITY SATELLITE ST. TALLAHASSEE TAMPA WEST PETERSBURG PALM... BEACH. BEACH

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