Florida Worker's Reimbursement RequestFlorida Worker's Reimbursement RequestFlorida Worker's Reimbursement Request
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SDTF RECEIVED DATE

REIMBURSEMENT REQUEST
FLORIDA DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
OFFICE OF SPECIAL DISABILITY TRUST FUND
200 East Gaines Street
Tallahassee, Florida 32399-4223

Note: This report must be signed by the employer or his duly authorized agent or carrier. Supporting records
are subject to audit by the Division of Workers’ Compensation. The signed original and one copy must be filed
with the Fund by the employer or carrier requesting reimbursement.
PLEASE PRINT OR TYPE
EMPLOYEE NAME

SDTF CLAIM NUMBER

DATE OF ACCIDENT

NAME OF EMPLOYER

CARRIER CODE #

SERVICE CO/TPA CODE #

IMPAIRMENT RATING

MMI DATE

BASE COMPENSATION RATE

COMPENSATION RATE
COMPENSATION RATE WITH S/S OFFSET $

PT DATE

%
PERMANENT IMPAIRMENT (D/A Before 1/1/94)

TEMPORARY TOTAL

PI DATE
IMPAIRMENT INCOME (D/A On or After 1/1/94)

From
TEMPORARY PARTIAL

To

From
WAGE LOSS

From
MEDICAL (PHYSICIAN FEES)

To

From
To
SUPPLEMENTAL INCOME BENEFITS (D/A On or After 1/1/94)