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CLAIMS-HANDLING ENTITY RECEIVED DATE EMPLOYEE EARNINGS REPORT SENT TO DIVISION DATE DIVISION RECEIVED DATE FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS’ COMPENSATION CAUTION FAILURE OR REFUSAL OF EMPLOYEE TO COMPLETE, SIGN, AND RETURN THIS REPORT WITHIN 21 DAYS AFTER THE DATE OF RECEIPT OF THE REQUEST MAY CAUSE PAYMENT OF BENEFITS TO STOP UNTIL SUCH TIME AS THE COMPLETED FORM IS FURNISHED TO THE REQUESTING PARTY..
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