Get the free first report of injury form florida

O. Box Number) City Employer City (State or Province) Age at Accident (Year) Number of Employees (Top Number) Employer State or Province Address/Location Name Employer City (State or Province) Date of Death (Month-Day-Year) Date and Time of Death AM PM Date and Time City/State/Province Address of Last Known Location (Street, Apt., City, State or province) Name Address of Last Known Address (Street, Apt., City, State or Province) Employer Address (Street, Apt., City, State or Province) Employer City (State or Province) Zip Code (3-10 digits) Employer Age (Year) Total Number of Employees (Top Number) Cause of Death/Incident (Surname, First Name, Middle Name, Number of Middle Names, etc.) This number may change due to changes to the information provided to the Department by the source. Click Here to see Instructions for Reporting a Death. Employers are asked to submit one of the following forms or letters of claim or insurance forms to verify the name of the deceased Employer: Please contact your state insurance authority to submit an insurance claim form, for example Florida State Insurance Commissioner's Office, Florida Board of Professional Counselors, etc. Death Certificate: Submit the death certificate by mail with proof of date of death. The death certificate must have a current date and time stamp.