Effective date: 6/30/2014

    (1) Instructions on or pertaining to forms promulgated under this chapter, are also rules under this chapter and forms shall be completed in accordance with such instructions. When forms are reproduced, they shall be reproduced in their entirety, including instructions. The claim administrator shall ensure that all documents filed with the Division pursuant to this rule chapter are complete and legible. These documents shall be filed with the Florida Department of Financial Services, Division of Workers’ Compensation, 200 East Gaines Street, Tallahassee, Florida 32399-4226, except as otherwise indicated. The Division shall return to the claim administrator any document on which the appropriate information required in subsection (3) of this rule and paragraph 69L-56.4011(1)(d), F.A.C., does not appear, and will notify the claim administrator of its error or omission. If a document is not complete and legible, the Division will return it to the claim administrator’s address as provided on the form for correction or completion. The claim administrator shall make the correction, include a revised “Sent to Division Date” and resubmit the document to the Division. The document will be considered completed and in compliance with this section when the corrected document is resent and accepted by the Division.

Terms Used In Florida Regulations 69L-3.003

  • Claim Administrator: means any insurer, claims-handling entity, qualified servicing entity, service company/third-party administrator (Service Co/TPA), self-serviced self-insured employer or fund, or managing general agent and includes all claims office locations that will be responsible for adjusting and submitting workers' compensation claims to the Division. See Florida Regulations 69L-3.002
  • Days: means calendar days unless otherwise noted. See Florida Regulations 69L-3.002
  • Document: means any notice, form, or report which shall be submitted to the Division under this chapter or which the Division requests in connection with any matter covered by this chapter. See Florida Regulations 69L-3.002
  • Filed: means a document has been received and accepted in accordance with rule 69L-3. See Florida Regulations 69L-3.002
  • Send: means to transmit a document to the party or parties intended to receive it, including by mail, hand delivery, or electronic transmission. See Florida Regulations 69L-3.002
    (2) Claim administrators shall respond to any written request for information by the Division no later than 14 days after receiving the request, except as otherwise provided in rule chapter 69L-3, F.A.C.
    (3) The claim administrator, where required, shall include on every document it submits to the Division the following information:
    (a) The employee’s name.
    (b) The employee’s social security number as assigned by the Social Security Administration. If the employee does not have a social security number, the claim administrator shall email the Division at DWCAssignedNumber@myfloridacfo.com to obtain a Division assigned number until the social security number is obtained. Upon receipt of the employee’s social security number, the claim administrator shall file Form DFS-F2-DWC-4, as adopted in rule 69L-3.025, F.A.C., with the Division in accordance with rule 69L-56.404, F.A.C.
    (c) The month, day, and year of the employee’s accident or illness, in the following order: mm-dd-yy or mm-dd-ccyy.
    (d) The “Insurer Code #”. A claim administrator adjusting claims for one or more insurers shall report the correct “Insurer Code #” for each specific claim.
    (e) The “Service Co/TPA Code #”. If a third-party administrator, servicing agent, or other claim administrator is servicing a claim for an insurer, self-insured employer or self-insurance fund, it shall include both the “Insurer Code #” and the “Service Co/TPA Code #” on any form.
    (f) The “Claims-handling Entity File #”. A claim administrator shall report its internal identification number assigned to a file on forms as required under this chapter.
    (g) The name, address and telephone number of the claim administrator. When a “Service Co/TPA” is adjusting claims for an insurer, the name, address and telephone number of the “Service Co/TPA” in addition to the name of the insurer shall be provided. The telephone number provided shall enable a caller to readily contact the office handling the claim.
    (h) The “Sent to Division Date”.
    (4) The insurer or the claim administrator shall provide a supply of Forms DFS-F2-DWC-1 and DFS-F2-DWC-1a, as adopted in rule 69L-3.025, F.A.C., to the employer, unless an alternative electronic reporting arrangement with the claim administrator is in place. The name of the insurer and the claim administrator’s name, address and telephone number shall be pre-printed or pre-stamped on each such form.
    (5) All submissions of forms promulgated under this rule shall conform with the promulgated form in design, layout, field size, content and shall contain all data elements required by the promulgated form. If the Division finds that a computer-generated form is not the same as the promulgated form, the Division will return the form and the claim administrator shall make the correction, include a revised “Sent to Division Date” and resubmit a corrected form to the Division. The document will be considered completed and in compliance with this section when the corrected document is resent to the Division and is accepted.
    (6) Any insurer or claim administrator failing to timely send documents promulgated under this rule chapter is subject to administrative fines assessed by the Division.
    (7) This rule does not supersede Division filing requirements found in rules 69L-56.301, 69L-56.304, 69L-56.3045, 69L-56.3012 and 69L-56.3013, F.A.C., and the filing requirements found herein only apply to circumstances under which a Petition for Variance or Waiver has been granted pursuant to section 120.542, F.S.
Rulemaking Authority 440.185(2), (5), 440.20(3), 440.207(2), 440.38(2), (5), 440.591 FS. Implements Florida Statutes § 440.185, 440.20, 440.51(8), (9). History—Originally numbered 38F-3.01, 3.02, 3.03, New 10-30-79, Amended 11-5-81, Formerly 38F-3.03, Amended 4-11-90, 1-30-91, 11-8-94, Formerly 38F-3.003, 4L-3.003, Amended 1-10-05, 6-30-14.