A copy of the form is found in Exhibit II with the numbers corresponding to the instructions below. These numbers are not on the forms the department will use to report wages . View Exhibit II in Adobe Acrobat format. These forms should be completed on a typewriter, as they are legal documents prescribed by Florida Statutes, and may become court documents. They must be legible and complete.
Instructions Enter the injured employee's complete name and address.
It is very important to enter the employee's correct mailing address since Workers' Compensation disability payments, when appropriate, will be mailed to this address. An incorrect address will delay their receipt. Enter the employee's home telephone number. Enter the employee's social security number. Enter the number of days worked during each weekly or biweekly period.