FIRST REPORT OF INJURY OR ILLNESS RECEIVED BY CLAIMS-

HANDLING ENTITY
SENT TO DIVISION DATE DIVISION RECEIVED DATE

FLORIDA DEPARTMENT OF FINANCIAL SERVICES Bureau of Deferred March 28th 2022 April 4th 2022
DIVISION OF WORKERS' COMPENSATION Compensation
For assistance call 1-800-342-1741 or
contact your local EAO Office

PLEASE PRINT OR TYPE EMPLOYEE INFORMATION

NAME (First, Middle, Last) Social Security Number Date of Accident (Month-Day-Year) Time of Accident
March – 12 – 2022
Hernan John Hernandez n/a
AM PM
10:37 x
HOME ADDRESS EMPLOYEE'S DESCRIPTION OF ACCIDENT (Include Cause of Injury)

Street/Apt #: 16430 SW 30th Street________________________

Hernan climbed a 15-foot ladder to get a better view of the roof and
installation points. While on the ladder, a palm frond fell from a nearby
City: Miramar______________ State: Florida________ Zip: 33027_____
palm tree, hitting Hernan on the head, causing him to slide down the
TELEPHONE 305-418-7236 Area Code 305 Number 305-418-7236
ladder falling to the sand. Hernan suffered multiple fractures on both
arms, his right leg, and a concussion.
OCCUPATION Electrician INJURY/ILLNESS THAT OCCURRED PART OF BODY AFFECTED

DATE OF BIRTH SEX

Multiple fractures on both arms, his Arms, his right leg, his head.
right leg, and a concussion.
__07_______ / __12_______ / M F
___1987______
x
EMPLOYER INFORMATION
FEDERAL I.D. NUMBER (FEIN) DATE FIRST REPORTED (Month/Day/Year)
10/03/2021
COMPANY NAME: Sunny Electric_____________________________ 945-57-3321
D. B. A.: Sunny Electric ________________________________________________

Street: 621 Casa Drive ___________________________________________ NATURE OF BUSINESS POLICY/MEMBER NUMBER

City: Miami__________ State: Florida_______ Zip: 32207______ Service Sector 2009999999

TELEPHONE 305-717-8269 Area Code 305 Number 305-717-8269 DATE EMPLOYED PAID FOR DATE OF INJURY

____09_____ / ___09______ / __2021_______ YES x NO

x
LAST DATE EMPLOYEE WORKED WILL YOU CONTINUE TO PAY WAGES INSTEAD OF

EMPLOYER'S LOCATION ADDRESS (If different) __12_______ / ___13______ / ___2021______

WORKERS' COMP? x YES

Street: LAST DAY WAGES WILL BE PAID INSTEAD OF

RETURNED TO WORK YES NO
IF YES, GIVE DATE _________ WORKERS' COMP
__n/a___________________________________________________________
___n/a______ / ____03_____ / ____26_____ / ____2022_____
City: ________________________ State: _______________ Zip: ______________
_________ /
LOCATION # (If applicable) ____________________________________________

DATE OF DEATH (If applicable) n/a RATE OF PAY HR WK

_________ / _________ / _________ $ _6,250________________ x MO

DAY
PLACE OF ACCIDENT (Street, City, State, Zip) PER

Street: 621 Casa Drive ____________________________________________ _______8_______________

Number of hours per day _______40_____________
City: Miami _________________ State: Florida ________ Zip: 32207__________ Number of hours per week _______5______________
COUNTY OF ACCIDENT Miami- AGREE WITH DESCRIPTION OF ACCIDENT? Number of days per week
Dade_____________________________________
x YES NO
x
Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured NAME, ADDRESS AND TELEPHONE OF
program, files a statement of claim containing any false or misleading information commits insurance fraud, punishable as provided in s. PHYSICIAN OR HOSPITAL
817.234. Section 440.105(7), F.S.
I have reviewed, understand and acknowledge the above statement. Jackson Memorial Hospital
1611 NW 12th Ave, Miami, FL
Hernan John Hernandez 03/26/2022__________________
EMPLOYEE SIGNATURE (If available to sign) DATE
33136, United States
305-811-5811
Geoffry Sunny_______________________________________________ 03/26/2022__________________
AUTHORIZED BY YES NO
x
EMPLOYER SIGNATURE DATE
EMPLOYER

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)

1(b) Indemnity Only Denied Case - DWC-12, Notice of Denial Attached Employee’s 8TH Day of Disability __12__ / __21__ / __2021___
TH
Entity’s Knowledge of 8 Day of Disability __1__ /___7__ / ___2022___

3. Lost Time Case - 1st day of disability __12__ / _13__ / ___2021__ Full Salary in lieu of comp? x YES Full Salary End Date __12__/ __12__ / _2021__

Date First Payment Mailed __12__ / ___15___ / __2021___ AWW ___$1,000.00___________________ Comp Rate _____$13,000/yr_________________

T.T. T.T. - 80% T.P. I.B. x P.T. DEATH SETTLEMENT ONLY

Penalty Amount Paid in 1st Payment $20,000.00___________ Interest Amount Paid in 1 st Payment $5,000.00_________
REMARKS: INSURER NAME Nationwide

CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE

INSURER CODE #
76930285
EMPLOYEE'S CLASS CODE
75959372
EMPLOYER'S NAICS CODE
57362920
Bureau of Deferred Compensation
200 East Gaines Street,
SERVICE CO/TPA CODE #
567027576
CLAIMS-HANDLING ENTITY FILE #
Tallahassee, FL 32399.
01793 850-488-7186

Form DFS-F2-DWC-1 (10/2016) Rule 69L-3.025, F.A.C.

DWC-1 Purpose and Use Statement

The collection of the social security number on this form is
specifically authorized by Section 440.185(2), Florida
Statutes. The social security number will be used as a unique
identifier in Division of Workers' Compensation database
systems for individuals who have claimed benefits under
Chapter 440, Florida Statutes. It will also be used to identify
information and documents in those database systems
regarding individuals who have claimed benefits under
Chapter 440, Florida Statutes, for internal agency tracking
purposes and for purposes of responding to both public
records requests and subpoenas that require production of
specified documents. The social security number may also be
used for any other purpose specifically required or authorized
by state or federal law.