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Get FL DFS-F2-DWC-1 2009

______________________ Number of hours per week City: _________________________ State: _______________ Zip: ______________ COUNTY OF ACCIDENT ______________________________________________ AUTHORIZED BY EMPLOYER YES NO CLAIMS-HANDLING ENTITY INFORMATION 1(a) Denied Case - DWC-12, Notice of Denial Attached 2. Medical Only which became Lost Time Case (Complete all required information in #3) Employee’s 8TH Day of Disability 1(b) Indemnity Only Denied Case - DWC-12, Notice of Denial Att.

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