Opinion
No. 86035.
May 16, 1996.
John F. Harkness, Jr., Executive Director, The Florida Bar, Tallahassee, Honorable John J. Lazzara, Judge of Compensation Claims, Tallahassee, and Honorable Michael J. DeMarko, Judge of Compensation Claims, Chairperson of Workers' Compensation Rules Committee, Pensacola, for Petitioner.
Sharon Press, Director, Dispute Resolution Center, Tallahassee, Florida, on behalf of a subcommittee of the Mediation and Arbitration Rules Committee; and Annemarie Craft, Tallahassee, Florida, on behalf of Florida Department of Labor Employment Security, Responding.
This matter is before the Court upon a report filed by the Workers' Compensation Rules Committee of The Florida Bar recommending emergency amendments to the Florida Rules of Workers' Compensation Procedure. We have jurisdiction pursuant to article V, section 2 (a) of the Florida Constitution.
A synopsis of the proposed amended rules was published for comment in The Florida Bar News. Upon the request of the chief judge of the First District Court of Appeal, we approved part B of the Florida Rules of Workers' Compensation Procedure relating to appellate procedure. See In re Amendments to the Fla. Rules of Workers' Comp. Pro., 664 So.2d 945 (Fla. 1995).
The Court has received comments concerning the remaining proposed amended rules and has held oral arguments on these proposed rules. After oral arguments, we directed the Workers' Compensation Rules Committee to consider several of the submitted comments. The committee thereafter submitted a supplemental report addressing these comments. Additionally, we received comments from a subcommittee of the Mediation and Arbitration Rules Committee. In response to the submitted comments and oral arguments, we have made the following substantive changes to the proposed rules.
We have also made some word changes throughout the rules, forms, and appendices which we do not list because we do not consider that these changes substantively after that was submitted.
Proposed rule 4.025 (b) is amended to specifically exclude a claim for reimbursement from the Special Disability Trust Fund from being consolidated with other claims not contained in a petition.
Proposed rule 4.028 (a)(5)(D) is amended to clarify that in cases in which an injured employee is required to exhaust all managed care grievance procedures before filing a petition for benefits under section 440.192 (3), Florida Statutes (1995), any claims for benefits under section 440.13 (2)(a) and (b), Florida Statutes (1995), brought after the grievance procedures required by section 440.134 (15) are exhausted are to be determined by a judge of compensation claims and not by administrative appeal brought under chapter 120, Florida Statutes (1995).
Proposed rule 4.310 (e) is revised to reflect that the mediator has ten days following the conclusion of the mediation conference to file a written report to the presiding judge as to the status of the case.
Proposed rule 4.361 (a) is revised to reflect that the mediator shall have control of the mediation and not just the mediation conference.
Accordingly, we now approve and adopt the remainder of the committee's proposed amendments as modified and reflected in the appendix to this opinion. New language is indicated by underscoring; deleted language is indicated by overstriking. Committee comments are included for explanation and guidance only and are not adopted as an official part of the rules. These amendments shall take effect upon the release of this opinion.
No motion for rehearing shall be entertained.
It is so ordered.
GRIMES, C.J., and OVERTON, SHAW, KOGAN, HARDING and ANSTEAD, JJ., concur.
FLORIDA RULES OF WORKERS' COMPENSATION PROCEDURE PART A I. TRIAL PROCEEDINGS RULE 4.010. SCOPE AND TITLE GENERAL PROVISIONS and promulgated pursuant to the legal authority of the Supreme Court of Florida with the authority of sections 440.271 and 440.29 (3), Florida Statutes, in and in Committee Notes 1979 Adoption. 1992 Amendment. 1995 Amendment. Editorial changes only. RULE 4.020. DEFINITIONS Throughout these rules, unless the context or subject matter otherwise requires: (a) "district court" means the District Court of Appeal, First District; (b) "clerk" means the clerk of the district court; (c) "division" means the Division of Workers' Compensation of the Florida Department of Labor and Employment Security; (d) "department" means the Florida Department of Labor and Employment Security; (e) "judge" means judge of compensation claims pursuant to chapter 440, Florida Statutes; (f) "chief judge" means the chief judge of compensation claims appointed by the Governor, serving in the Department of Labor and Employment Security, pursuant to chapter 440 Florida Statutes; (g) in construing these rules, when the context indicates, the singular includes the plural and vice versa; (h) filing shall be accomplished by placement with the division, the judge of compensation claims, or the clerk of the district court as the context of chapter 440, Florida Statutes, or these rules requires; (i) "carrier" means any licensed insurance carrier, self-insured employer, self-insurance, fund or pool providing workers' compensation insurance coverage pursuant to chapter 440, Florida statutes, and includes the servicing agents of self-insureds; (j) "claimant" means any person making a claim for workers' compensation benefits or payments as permitted by chapter 440, Florida Statutes. A "claimant" is a party within the meaning of these rules; (k) "pleading" means any paper or document filed under these rules invoking the jurisdiction of or seeking relief from the judge of compensation claims or any court under chapter 440, Florida Statutes. The following definitions apply to all workers' compensation proceedings. (a) "Carrier" means any licensed insurance carrier, self-insured employer, self-insurance fund, or pool providing workers' compensation insurance coverage under chapter 440, Florida Statutes, and includes the servicing agents of self-insureds. (b) "Chief judge" means the chief judge of compensation claims appointed by the Governor, serving in the Department of Labor and Employment Security under chapter 440, Florida Statutes. (c) "Claim" means any element of a petition for benefits or other entitlement for which judicial relief is sought. A claim not contained in a petition for benefits may be made only under rule 4.025. (d) "Clerk" means the clerk of the District Court of Appeal, First District. (e) "Department" means the Florida Department of Labor and Employment Security. (f) "District Court" means the District Court of Appeal, First District. (g) "Division" means the Division of Workers' Compensation of the Florida Department of Labor and Employment Security. (h) "Docketing judge" means one or more judges designated by the chief judge pursuant to section 440.45 (3), Florida Statutes. (i) "EAO" means the Employee Assistance and Ombudsman Office created by section 440.191, Florida Statutes. (j) "Facsimile" means the electronic transmission of documents by electronic signal that, when received, can be transformed by electronic means and stored on paper, microfilm, magnetic storage device, optical disk, or other storage media. (k) "Filing" means delivery to the division, the judge, or the clerk of the district court as the context of chapter 440, Florida Statutes, or these rules requires. fn (l) fn "Forms" means forms incorporated in these rules and promulgated pursuant to chapter 440, Florida Statutes. fn (m) "Impasse" means the parties' inability to reach a mutually acceptable and voluntary agreement as to any matter at the mediation conference. fn (n) "Informal dispute resolution" means the procedure established by section 440.191, Florida Statutes. fn (o) fn "Joint petition" means a pleading filed jointly by the parties seeking approval of the stipulation in which the claimant receives a lump-sum payment of past or future benefits, or a combination of both, or a release of a lien against a third party, in exchange for releasing the carrier from liability for certain benefits as allowed under section 440.20 (11), Florida Statutes. fn (p) "Judge" means judge of compensation claims pursuant to chapter 440, Florida Statutes. fn (q) "Mediation agreement," also known as a "mediation settlement agreement," means a mutually acceptable and voluntary written or recorded agreement reached by the parties at a mediation conference, with the assistance of a mediator, resolving completely or partially a workers' compensation dispute or claim. fn (r) "Mediation conference" means an informal, nonadversarial negotiation or settlement conference attended by the interested parties and supervised and conducted by a mediator. fn (s) "Mediator" means the person who conducts a mediation conference. fn (t) "Parties" include the employee, claimant, employer, carrier, health care provider, and division. fn (u) "Petition for benefits" means a pleading meeting, specifically but not limited to, the requirements of sections 440.192 (1)-(4), Florida Statutes, that invokes the jurisdiction of the judge. fn (v) "Petitioner" or "claimant" means any person making a claim. A "petitioner" or fn "claimant" is a party within the meaning of these rules. fn (w) "Pleading" means any paper or document filed under these rules invoking the jurisdiction of or seeking relief from the judge or any court under chapter 440, Florida Statutes. The request for assistance or other contact with the EAO is not a pleading that invokes the jurisdiction of the judge. fn (x) "Procedural motion" means a motion relating to procedure or discovery that does not seek adjudication of entitlement to benefits. Motions that do not seek adjudication of entitlement to benefits and are based upon stipulated facts requiring no other evidence also shall be treated as procedural motions. fn (y) "Request for assistance" means the initiation of the informal dispute resolution procedure established by section 440.191, Florida Statutes. fn (z) "Verified pleading" means a pleading the facts of which are attested to under oath. fn Committee Notes 1979 Adoption. 1988 Amendment. 1995 Amendment. fn Many new definitions were added and the list was alphabetized. fn RULE 4.022. FORMS OF fn PLEADING S AND PROPOSED ORDERS fn (a) fn Generally. fn All fn P fn p fn in proceedings before the judge of compensation claims under these rules fn unless otherwise ordered by the judge of compensation claims. fn (and fn including fn or subpoenas, if originated by a party or an attorney) fn (1) be typewritten or printed on 8 1/2" by 11" bond paper; fn (2) fn and/ fn . fn ; and fn (3) fn All pleadings shall fn Attorneys shall include their Florida Bar number. fn Pleadings shall be typewritten or printed on 8 1/2" by 11" bond paper. fn (b) fn Proposed Orders. fn except as otherwise provided in these rules fn unless otherwise directed by the judge, fn , fn and fn the use of fn of compensation claims together with fn , and fn postage-paid fn A copy of any proposed order shall be sent to opposing counsel and any party not represented. fn Committee Notes 1988 Adoption. 1995 Amendment. fn Aligns pleadings in workers' compensation matters with those in the court system. fn Section 440.32 (3), Florida Statutes, requires that every pleading be signed by the attorney of record regardless of whether the claimant or petitioner executes the pleading. fn RULE 4.023. CONTRACT OF REPRESENTATION fn (a) fn Approval of Contract. fn (1) The claimant and the attorney for the claimant may jointly apply to the judge having jurisdiction of the industrial accident to approve the contract of representation and enforce its provisions. fn (2) The judge may approve the contract of representation without a formal hearing if it appears to be in substantial compliance with these rules and the provisions of chapter 440, Florida Statutes. fn (3) Upon approval of the contract of representation without a formal hearing, the judge shall enter an order and serve a copy of the order on the attorney for the claimant. fn (4) The attorney for the claimant shall promptly serve a copy of the order on all parties and counsel of record using the certificate of service provided in form 4.902. fn (b) fn Motion to Modify or Vacate Order Approving Contract. fn (1) Any party, for good cause, may object to and move to modify or vacate any order approving a contract of representation at any time. fn (2) The filing and service of a motion to modify or vacate an order approving a contract of representation shall suspend the operation and effect of the order until the motion is heard and decided. fn (3) The judge shall hear such motions promptly. fn (c) fn Modification or Disapproval. fn Nothing in this rule shall preclude the judge from modifying or disapproving any contract of representation for good cause or to avoid undue hardship to any party. fn Committee Notes fn 1995 Adoption. fn From former rule 4.061 (a). Approval of any contract of representation by the judge of compensation claims is discretionary and not mandatory. fn RULE 4.024. REPRESENTATION AND APPEARANCE OF COUNSEL fn (a) fn Appearance of Counsel. fn An attorney who undertakes representation of a party in a workers' compensation matter shall file promptly a notice of appearance and serve copies to all parties including counsel of record. The notice of appearance shall be one page in length, bear the style and caption provided in form 4.901, and include the name, address, telephone number, and Florida Bar number of counsel. fn The following shall suffice as notice of appearance: fn (1) the service by the claimant's attorney of the order approving the contract of representation under rule 4.023; fn (2) the filing of a notice of appearance with the division if no claim, application for hearing, request for assistance, or petition has been filed; and fn (3) the filing of a notice of appearance with the presiding judge after a claim, application for hearing, request for assistance, or petition has been filed; fn (b) fn Substitution of Counsel. fn Co-counsel or any successor attorney shall file a notice of appearance in accordance with the rules. Substitution of counsel may be made: fn (1) by the filing and service of a stipulation, which does not require the approval of the judge; fn (2) by motion, which requires approval of the judge. fn (c) fn Withdrawal of Counsel. fn An attorney of record shall remain attorney of record and not be permitted to withdraw unless: fn (1) the attorney files a written motion for withdrawal setting forth the reasons for the motion; fn (2) the motion is served on the client and counsel for all parties; and fn (3) an order is entered granting the motion of withdrawal. fn (d) fn Hearing. fn If requested by any party, or on the judge's own motion, a hearing may be held to protect the rights of all parties. fn (e) fn Order. fn The judge may, without a hearing, enter an order substantially the same as form 4.907. fn Committee Notes fn 1995 Adoption. fn This replaces rule 4.060 and further clarifies existing procedure as to appearance and substitution of counsel. fn RULE 4.025. CLAIMS NOT CONTAINED IN PETITION fn (a) fn Generally. fn Claims not contained in a petition shall be filed with the division at its office in Tallahassee and served pursuant to rule 4.030. Claims shall be subject to adjudication by the judge or reviewing court but shall not be subject to the informal dispute resolution process or review by the docketing judge. Claims shall be limited to the following subjects: fn (1) fn Modification of Prior Compensation Order. fn Application for modification of an order under section 440.28, Florida Statutes, shall be substantially in the form of a petition under section 440.192 (2), Florida Statutes, fn and shall include a request for a hearing. Adjudication shall be in the manner provided in rules 4.045, 4.075, and 4.085. fn (2) fn Claim for Reimbursement From Special Disability Trust Fund. fn A claim for reimbursement from the Special Disability Trust Fund filed under section 440.49 (7), Florida Statutes, shall be made under the administrative rules promulgated by the division. Adjudication of such a claim shall be in the manner provided in rules 4.045, 4.075, and 4.085. fn (3) fn Claims against Third Parties. fn The employer or its carrier may at any time file a claim seeking reimbursement, contribution, indemnification, or exoneration from any third party. Adjudication of such a claim shall be in the manner provided in rules 4.045, 4.075, and 4.085. fn (4) fn Claims Limited to Attorney Fees and/or Taxable Costs. fn Claims limited to attorney fees and/or taxable costs when benefits have been paid previously and provided or awarded shall be handled under rule 4.144. fn (b) fn Consolidation of Claims. fn On the judge's own motion, or on the motion of any party, the judge may consolidate any of the aforementioned claims, except for a claim for reimbursement from the Special Disability Trust Fund referred to in subdivision (a)(2), with any pending petition for the purpose of a hearing or for any other purpose. fn Committee Notes fn 1995 Adoption. fn This rule defines the types of claims not included in a petition for benefits filed under section 440.192, Florida Statutes, that bypass the request-for-assistance process in section 440.191 (2)(a), Florida Statutes, and the docketing judge's review under section 440.45 (3), Florida Statutes. fn RULE 4.026. EXEMPTIONS FOR COLLECTIVE BARGAINING AGREEMENTS fn If authorized by a collective bargaining agreement filed with the division under section 440.211, Florida Statutes, the informal dispute resolution process, review by the docketing judge, or adjudication by a judge may be replaced by an alternative dispute resolution system that may supplement, modify, or replace the provisions of chapter 440, Florida Statutes. fn Committee Notes fn 1995 Adoption. fn This rule recognizes an alternative dispute process other than that expressed in chapter 440, Florida Statutes. fn RULE 4.027. VENUE fn (a) fn Generally. fn Venue shall be governed by section 440.25 (4)(d), Florida Statutes. fn (b) fn Consolidated Petitions. fn If a party's entitlement to benefits arises or may arise from two or more accidents in different venues against one or more employer/carriers, the party may file a consolidated petition or claim against both or all employer/carriers. Venue shall be determined by order of the chief judge or by agreement of the parties. fn (c) fn Motion. fn A motion for consolidation shall be made to a presiding judge who shall forward the motion to the chief judge for determination. fn Committee Notes fn 1995 Adoption. fn This rule intends to avoid the confusion as to the proper venue when there are two or more accidents in different venues involving the same or different employer/carriers. fn RULE 4.028. PETITION FOR BENEFITS fn (a) fn Generally. fn (1) fn Service. fn A petition under chapter 440, Florida Statutes, shall be served by certified mail upon the employer, carrier, and the division in Tallahassee. Counsel for each party and any unrepresented party shall be served under rule 4.030. Upon receipt of the petition, the division shall forward it immediately to the docketing judge pursuant to section 440.192 (2), Florida Statutes. fn (2) fn Form. fn A petition shall meet the specificity requirements of sections 440.192 (2) and (3), Florida Statutes, shall include a request for a hearing, and shall be in substantial compliance with the forms of these rules. The judge may request the EAO to assist unrepresented employees in filing a petition, as provided in section 440.192 (2), Florida Statutes. fn (3) fn Notice. fn A petition shall contain the fraud notice contained in section 440.105 (7), Florida Statutes, and shall personally be signed and attested to by the petitioner. fn (4) fn Certificate of Good-Faith Effort. fn A petition must include a certificate by the claimant or, if the claimant is represented by counsel, by the claimant's attorney stating the claimant or attorney has made a good-faith effort to resolve the dispute and the claimant or attorney was unable to resolve the dispute with the carrier. fn (5) fn Certificate of Completion of Informal Administrative Remedies. fn A petition shall also include a certificate that one of the following has occurred: fn (A) The informal dispute resolution process required by section 440.191, Florida Statutes, has been concluded. fn (B) The EAO has declined to consider the matter. fn (C) The parties were unable to resolve the dispute within 30 days after a request for assistance was made to the EAO. fn (D) If medical care is being provided to the employee through managed care and the petition includes a claim for medical care under section 440.13 (2)(a) and (b), Florida Statutes, the certificate must indicate that the grievance procedures required by section 440.134 (15), Florida Statutes, were exhausted before filing the petition under section 440.192 (3), Florida Statutes. fn (b) fn Amended Petition for Benefits. fn A petition cannot be amended except by stipulation of the parties and approval by the judge. Such an amended petition shall not be subject to the informal dispute process or review by the docketing judge. fn (c) fn Employer/Carrier Petition for Benefits. fn The employer or carrier may file a petition seeking an adjudication of any issue. fn (d) fn Consolidation. fn Successive petitions may be consolidated by the judge on his or her own motion or on the motion of any party for purposes of any proceeding under chapter 440, Florida Statutes. fn Committee Notes fn 1995 Adoption. fn Replaces rules 4.050 and 4.070. This rule is intended to standardize the form for a petition for benefits and the preparation of such forms by counsel resulting from the 1993 amendments to chapter 440, Florida Statutes. The request or application for hearing is now incorporated in the petition and no longer a separate pleading. fn The grievance procedures referred to in subdivision (a)(5)(D) are the procedures required by section 440.134 (15), Florida Statutes, and not chapter 120, Florida Statutes. fn RULE 4.029. REVIEW BY DOCKETING JUDGE fn (a) fn Generally. fn After receiving the petition, the division shall forward the petition immediately and all attachments filed with or received by the division to the docketing judge. fn (b) fn Review. fn After receiving the petition from the division, the docketing judge shall promptly review the petition and attachments to determine if the requirements of sections 440.192 and 440.32 (3), Florida Statutes, have been met and the matters in dispute have been acted on by the EAO. fn (c) fn Dismissal of Petitions Without Prejudice. fn If the issues raised in the petition do not meet the requirements of sections 440.192 (2)-(4), Florida Statutes, or the petitioner did not exhaust the EAO administrative remedies, the docketing judge shall summarily dismiss the petition without prejudice with leave to amend within 30 days. fn (d) fn Dismissal of Petitions With Prejudice. fn If the petition does not meet the requirements of sections 440.192 (2)-(4), Florida Statutes, and these rules, and the judge intends to dismiss the petition with prejudice, the judge may do so only after first giving the parties a reasonable opportunity to be heard. fn (e) fn Extension of Mediation, Pretrial, and Final Hearing Deadlines. fn If the judge intends to dismiss the petition with prejudice, the judge must conduct a hearing on the matter after giving the parties 5 days' written notice. The parties may appear by telephone at any such hearing in accordance with procedures established under these rules for fn telephone hearings. Statutorily mandated mediation, pretrial, and final hearing deadlines shall be extended if a hearing under this subdivision is required. fn (f) fn Petition that Meets Statutory Requirements. fn If the docketing judge determines the petition meets all statutory requirements, the judge shall so indicate and immediately forward the petition to the appropriate district. fn Committee Notes fn 1995 Adoption. fn The docketing judge's ruling on specificity under section 440.192, Florida Statutes, or on the issue of whether the allegations contained in the petition were well grounded as required under section 440.32 (3), Florida Statutes, is not a final determination on either issue. Subject to the time limitations of section 440.192 (5), Florida Statutes, a motion to dismiss for lack of specificity or for failure to exhaust EAO remedies may be filed with the presiding judge. The same is true for a motion to strike or dismiss the petition for lack of an appropriate signature or for a motion to impose a sanction under section 440.32 (3), Florida Statutes. fn RULE 4.030. FILING AND SERVICE Filing. otherwise fn Method and Proof fn of Service. Same; fn How Service Is fn Made. When service is required or permitted to be made on a party represented by an attorney, service shall be made on the attorney unless service on the party is ordered by the court. Service on the attorney or party shall be made by delivering a copy to the attorney's or party's last known address. fn a fn A fn , fn ; fn or fn b fn B fn (c) fn , fn ; fn or fn d fn C fn , fn ; fn or fn e fn D fn by fn placing it in the fn , postage prepaid, to the last known address of the party or attorney. Service by mail shall be complete upon mailing. fn ; or fn (E) transmitting it by facsimile. fn Service by delivery or by facsimile after 5:00 p.m. shall be deemed to have been made on the next day that is not a Saturday, Sunday, or legal holiday. fn The use of facsimile machines also is permitted when available. When a facsimile machine is used, a cover sheet providing the sender's name and telephone number shall be included and a copy of the document shall be sent simultaneously to the recipient by mail. The sending party shall retain proof of transmission. Delivery shall be complete on transmission of a complete facsimile of the document. fn (2) fn Service by Mail. fn (A) When service is made by mail, the copy shall be mailed by United States mail, postage prepaid, to the last known address of the party or attorney. Petitions must be sent by certified mail. fn (B) Service by mail shall be complete upon mailing. fn (C) Except for a petition, when service is made by mail, 5 days shall be added to the time allowed for the performance of any act required to be done, or allowed to be done, within a certain time after service. This does not apply to filing requirements for institution of appellate proceedings or notices of hearings. fn (3) fn Service by Facsimile Device. fn (A) When a facsimile device is used, a cover sheet or its equivalent providing the sender's name and telephone number shall be included and a copy of the document shall be sent simultaneously to the recipient by mail. fn (B) The sending party shall retain proof of the transmission. fn (C) Delivery shall be complete on transmission of a complete facsimile of the document. fn 2 fn c fn Certificate of Service. (c) fn Service by Mail. fn When service is effectuated by mail, 5 days shall be added to the time allowed for the performance of any act required to be done, or allowed to be done, within a certain time after service. (This subdivision does not apply to the filing requirements for institution of appellate proceedings or notices of hearing.) fn Subpoenas. Committee Notes 1979 Adoption. 440.25 1984 Amendment. 1988 Amendment. 1995 Amendment. fn Further clarifies method of service of pleadings and specifically includes service by facsimile device. fn RULE 4.045. PRETRIAL PROCEDURE fn (a) fn Generally fn The judge shall, on a motion by any party, hold a pretrial hearing. If no pretrial hearing has been noticed previously, the judge shall schedule a pretrial hearing after receiving a notice of impasse from the mediator. fn (b) fn Notice of Pretrial. fn The judge shall give parties at least 7 days notice of a pretrial hearing and may combine the notice of the pretrial hearing with the other notices. Unless the judge indicates otherwise, pretrial hearings will be held in the county where the judge's office is located. fn (c) fn Continuance. fn Pretrial hearings may be continued or extended with prior approval of the judge. fn (d) fn Appearance of Counsel. fn Counsel for the parties shall appear at the pretrial conference. If attendance is not waived by the judge following proper notice, nonlocal attorneys, as defined in the pretrial order, may appear by phone. fn (e) fn Telephone Hearing. fn The judge may conduct the pretrial hearing by telephone at the request of any party or on the judge's own motion, provided all parties are represented by counsel. fn (f) fn Waiver of Hearing. fn If all parties are represented by counsel, the judge may waive attendance or cancel the pretrial hearing if a written pretrial stipulation is filed with the judge before the date of the pretrial hearing. In such cases, all parties will be presumed to have a full and complete understanding of all issues involving benefits claimed, the defenses asserted, the witnesses to be presented, and the exhibits to be introduced into evidence. fn (g) fn [Attendance. fn If a party or a party's attorney fails to attend the hearing without good cause, the judge may dismiss the petition or claim, strike defenses, or take such other action as may be authorized by law or rule 4.150. fn (h) fn Purpose of Pretrial. fn At the pretrial conference, the parties shall: fn (1) state and simplify the claims, defenses, and issues; fn (2) stipulate and admit to such facts and documents as will avoid unnecessary proof; fn (3) present, examine, and mark all exhibits for identification, including all impeachment and rebuttal exhibits; fn (4) furnish the opposing party the names and addresses of all witnesses, including impeachment and rebuttal witnesses. A party may be required to provide a statement of subject matter of the expected testimony of one or more witnesses; fn (5) exchange all available written reports of experts when expert opinion is to be offered at trial. The reports should clearly disclose the expert opinion and its basis on all subjects on which the expert will testify. If stipulated into evidence, the reports shall be presented to the judge to be so marked. The parties shall consider and determine a imitation of the number of expert witnesses; fn (6) estimate trial time and schedule the final hearing; and fn (7) consider and determine such other matters as may aid in the disposition of the case, including referral to additional mediation. fn (i) fn Forms of Stipulations. fn The appropriate pretrial stipulation and pretrial compliance questionnaire shall be used. Final witness and exhibit lists, and any supplements to the pretrial stipulation, shall be filed at the pretrial hearing or 30 days before the final hearing. Exhibits shall be attached to the pretrial stipulation. Witness lists, exhibit lists, and supplements served after the pretrial hearing must first be approved by the judge. A motion seeking such approval is a procedural motion. fn (j) fn Motion Hearings at Time of Pretrial. fn At the discretion of the judge and on filing and service of motion and notice of hearing not less than 5 days before the date of the pretrial hearing, procedural motions may also be heard at the time of the pretrial hearing. fn (k) fn Pretrial of Penalty Hearings. fn (1) When an employer or carrier has protested an assessment by the division of penalties, fines, or interest under sections 440.185 or 440.20, Florida Statutes, the judge shall cancel and waive attendance at a pretrial hearing regarding a hearing on such penalties, fines, or interest if a written pretrial stipulation is filed with the judge before the date of any scheduled pretrial hearing. fn (2) Pretrial stipulations regarding penalties, fines, or interest assessed against an employer or carrier shall be substantially the same as form 4.916. fn (3) The division shall complete its portion of the pretrial stipulation and mail or otherwise deliver the original and one copy to the employer or carrier. The division shall file a notice of filing with the judge indicating the stipulation has been delivered to the employer or carrier for completion. The employer or carrier shall complete its portion of the pretrial stipulation and file the original with the judge and simultaneously mail or otherwise deliver a copy to the division and to the general counsel of the department. fn (l) fn Record. fn The judge shall record the pretrial healing by stenographic or electronic means at the request of any party or by a written stipulation signed by the parties. fn (m) fn Pretrial Order. fn (1) At the request of any party or by his or her own motion, the judge promptly shall enter an order reciting the actions taken at the pretrial hearing and the agreements made by the parties about any of the matters considered and limiting the issues for trial to those not disposed of by admissions or stipulations of parties. fn (2) The order shall control the subsequent course of the action unless the judge modifies to prevent injustice. fn (3) The judge shall serve the order on the attorneys for the parties and on any party not represented by counsel. fn (4) Unless otherwise specified in the notice of hearing, the judge may consider and determine all issues pending as of the date of the pretrial hearing. fn (n) fn Setting and Noticing Final Hearing. fn If the date is not already set, the judge shall set the date of the final hearing at the pretrial hearing. The notice of the final hearing may be set forth in the pretrial order accompanying the pretrial stipulation or may be mailed separately by the judge to all interested parties. fn Committee Notes fn 1995 Adoption. fn Replaces rule 4.100, but includes many of the provisions of the previous rule. Requires a judge of compensation claims to schedule a pretrial hearing after receipt of a mediator's report declaring an impasse as per section 440.25 (4)(a), Florida Statutes. fn Provides for pretrial of protested penalty assessment orders and the method thereof. Clarifies when personal appearances may be waived and prescribes the form of the pretrial stipulation. Requires furnishing names and addresses of all witnesses to be used at trial, including impeachment and rebuttal witnesses. fn RULE 4.050. CLAIMS fn Claims and notices to controvert shall be filed with the division at its office in Tallahassee. Claims shall be subject to adjudication by the judge of compensation claims or reviewing court. fn Committee Notes fn 1979 Adoption. fn This replaces rule 4, 1977 W.C.R.P. fn It appears to be the view of the Division of Workers' Compensation (hereafter "Division") that the filing of a claim, the form of that claim, and all massaging of that claim prior to the same being assigned to a deputy commissioner [for judicial function] pursuant to an application for hearing, is solely and totally within the purview of the division and ought not be addressed by these Workers' Compensation Rules of Procedure, or any other rules except those of the division. Section 440.19(2)(d), Florida Statutes (1979), provides that: fn Such claim shall be filed with the division at its office in Tallahassee and shall contain the name and address of the employer, and a statement of the time, place, nature, and cause of the injury, of such fairly equivalent information as will put the division and the employer on notice with respect to the identity of the parties and the specific compensation benefit which is due but has not been paid or is not being provided. Any claim, or portion thereof, not in compliance with this subsection shall be subject to dismissal upon motion of the deputy commissioners. fn Cf. § 440.25(1) Fla.Stat. (1979); § 440.20(10)(b), Fla.Stat. (1979). fn This differs radically from the traditional source of creating and disciplining the pleading by which civil actions are initiated. fn 1984 Amendment. fn Derived from section 440.271, Florida Statutes, and rule 20, Florida Workers' Compensation Rules of Procedure. Providing for exclusive adjudicatory powers in workers' compensation matters with the deputy commissioner or reviewing court rather than the Division of Workers' Compensation. fn RULE 4.051. CONSOLIDATION OF CLAIMS fn Judges of compensation claims may, on their own motion or on the motion of any party, consolidate claims for the purpose of hearings or for any other purpose. fn Committee Notes fn 1988 Adoption. fn This rule formalizes existing procedure for consolidation of claims. fn RULE 4.052. THIRD-PARTY PRACTICE fn The employer or its carrier (or servicing agent) may at any time file a claim seeking reimbursement, contribution, indemnification, or exoneration from any third party. fn Committee Notes fn 1988 Adoption. fn This rule is intended to provide for the joinder of additional parties defendant by the employer or its carrier by the filing of a claim rather than by motion or other pleading. fn RULE 4.055. DISCOVERY fn (a) fn Jurisdiction. fn The judge shall have jurisdiction to take appropriate action to compel discovery, including the imposition of sanctions and, as circumstances warrant, may enlarge or shorten the applicable time for complying with discovery. fn (b) fn When Discovery May Be Had. fn Discovery under this rule may be had before or after the filing of a claim or petition, in the same manner and for the same purpose as provided in the Florida Rules of Civil Procedure or section 440.30, Florida Statutes. At the pretrial hearing, the judge shall set a date for the final hearing that allows the parties at least 30 days to conduct discovery unless the parties consent to an earlier hearing date. fn (c) fn Types of Discovery Not Permitted. fn Interrogatories, requests for admission, and other forms of discovery not authorized by these rules shall not be permitted or used in workers' compensation proceedings. fn (d) fn [Depositions. fn (1) Depositions of witnesses or parties may be taken and used in proceedings under chapter 440, Florida Statutes, in the same manner and for the same purposes as provided in the Florida Rules of Civil Procedure or as otherwise provided by law. fn (2) For good cause shown, the judge may require taking a deposition by telephone. fn (3) If a deposition is taken by telephone, the oath shall be administered in the physical presence of the witness by a notary public or officer authorized to administer oaths. A certificate of the notary public or officer, substantially the same as form 4.9105, shall be filed by the party offering the witness's deposition within 15 days. fn (e) fn Production of Documents and Entry on Land. fn (1) The parties shall be subject to discovery procedures seeking the production of records or other tangible things, including, but not limited to, all hospital and medical records pertaining to the industrial accident, all rehabilitation reports, all records pertaining to the claimant's average weekly wage at the time of the accident or earnings made subsequent to the industrial accident, and a transcript of any recorded statements of a party. fn (2) The parties shall be subject to discovery procedures seeking entry on land or other property for inspection or other purposes within the scope of discovery. fn (3) The parties shall have 30 days to serve a written response after service of any request under this rule. fn (f) fn Production of Documents from Nonparties. fn The parties may seek the production of documents and other tangible things within the scope of discovery for inspection and copying from a person who is not a party pursuant to applicable Florida Rules of Civil Procedure, except that the time for objection to production of documents under this rule is reduced to 5 days. fn (g) fn Surveillance. fn The evidence of any investigator, adjuster, or other witness in the nature of surveillance shall be subject to discovery when such evidence will be used at trial, provided the party intending to use such evidence is first given a reasonable opportunity to depose the party or witness who is the subject of the surveillance. fn Committee Notes fn 1995 Adoption. fn Replaces rule 4.090. Provides for deponent's oath when deposition taken by telephone. Limits objection to notice of production from nonparty to 5 days, rather than 10 days as required by Florida Rule of Civil Procedure 1.351. fn RULE 4.056. RIPENESS fn At any time during any proceeding, on the motion of any party or on the judge's own motion, the judge of compensation claims may make a determination of the ripeness for adjudication of any pending claim or defense or element thereof. The judges of compensation claims may, in their discretion take such testimony, hear such argument, fn and enter such orders as may be necessary to determine the ripeness of an issue. To protect the interests of any party and to advance the proceeding, the judge of compensation claims may fn (a) sever any issue; fn (b) continue a scheduled hearing as to any or all issues; fn (c) reserve jurisdiction of any issue; or fn (d) dismiss any issue without prejudice. fn In determining the ripeness of any issue, the judge of compensation claims shall consider whether the opposing party has had adequate time within which to prepare to litigate the issue, taking into account the due diligence of the parties. fn Committee Notes fn 1988 Adoption. fn This rule recognizes the serial nature of claims and defenses as they arise under chapter 440, Florida Statutes. It codifies existing procedure to permit the deputy commissioner to adjudicate issues as they become ripe. fn RULE 4.058. PETITION FOR MODIFICATION; PETITION FOR REIMBURSEMENT FROM SPECIAL DISABILITY TRUST FUND fn Petitions for modifications pursuant to section 440.28, Florida Statutes, and petitions for reimbursement from the Special Disability Trust Fund pursuant to section 440.49(2), Florida Statutes, shall be made substantially in the form of a claim. Adjudication of a petition under this rule shall be in the manner provided in these rules for the disposition of claims and defenses. fn RULE 4.060. REPRESENTATION AND APPEARANCE OF COUNSEL; SUBSTITUTION OF COUNSEL; WITHDRAWAL OF COUNSEL fn (a) fn Appearance of Counsel. fn An attorney undertaking the representation of a party to a proceeding under these rules shall promptly file with the division a notice of appearance, not to exceed one page in length, prior to the filing of an application for hearing, or with the office of the judge of compensation claims having, jurisdiction of the industrial accident after a filing of an application for hearing. The notice shall bear the style and caption provided in form 4.901 and include the address and telephone number of counsel. A claim or application for hearing signed by counsel and containing the address and telephone number of counsel shall suffice as a notice of appearance. Notice of appearance shall be filed by any successor or associated attorney, prior to or concurrently with the filing of any pleading or presentation of oral argument to or before a judge of compensation claims or the district court. fn (b) fn Substitution of Counsel. fn Substitution of counsel may be effected by the filing and service of a stipulation, for which no approval of the judge of compensation claims is required, or by motion. fn (c) fn Withdrawal of Counsel. fn An attorney who has filed a claim or has otherwise become an attorney of record for any party to a workers' compensation cause shall remain attorney of record in said cause and shall not be permitted to withdraw from the cause unless the attorney first filed with the judge of compensation claims a written motion for withdrawal setting forth the reasons therefor serving a copy of said motion on the movant's client and counsel for the adverse party, and then shall obtain from the judge of compensation claims an order granting such motion for withdrawal. If appellate proceedings have been instituted in the cause, the motion shall be filed with the appropriate court. Upon the filing of a motion to withdraw as counsel, the judge of compensation claims hearing jurisdiction of the industrial accident may conduct such hearings as may be requested by any party or on the judge's own motion to protect the rights of all parties; or the judge of compensation claims may enter an order substantially in the form provided in form 4.907. fn Committee Notes fn 1979 Adoption. fn This replaces rule 6, 1977 W.C.R.P. fn 1988 Amendment. fn This rule clarifies existing procedure as to the appearance and substitution of counsel and provides for an alternate procedure to approve the withdrawal of counsel without a hearing in the absence of a timely objection. fn RULE 4.061. CONTRACTS OF REPRESENTATION; ATTORNEY FEES fn (a) fn Contracts of Representation. fn The employee (or claims and the attorney for the employee (or claims may jointly apply to the judge of compensation claims having jurisdiction of the industrial accident to approve their contract of representation and enforce the provisions thereof. The judge of compensation claims may approve the contract of representation without a formal hearing if it appears to be in substantial compliance with these rules and the provisions of chapter 440, Florida Statutes. Upon approval of the contract of representation without a hearing, the judge of compensation claims shall enter an order and serve a copy of the order on the attorney for the employee. The attorney for the employee shall promptly a copy of the order on all parties and counsel of record using the certificate of service provided in form 4.902. Any party, for good cause shown, may object to and move to modify or vacate any order approving a contract representation at any time. The judge of compensation claims shall promptly hear any such motion. The filing and service of a motion to modify or vacate an order approving a contract of representation shall suspend the operation and effect of the order until the motion is heard and decided. Nothing in this rule shall preclude the judge of compensation claims from modifying or disapproving any contract of representation for good cause or to avoid undue hardship on any party. fn (b) fn Payment of Undisputed Attorney Fees. fn The employee and the attorney for the employee may jointly move for the judge of compensation claims to approve the payment of an attorney fee and reimburse of costs pursuant to a contract of representation by a stipulated motion substantially in the form provided by these rules. The employee and the employer and its carrier (or servicing agent) and/or their counsel may stipulate to the payment of an attorney fee and costs and submit their stipulate to the judge of compensation claims for approval. fn (c) fn Disputed Attorney Fee or Costs. fn A claim for attorney fees or costs brought by an attorney or party shall be in the form provided for a claim for compensation and shall be treated as a claim for compensation for all purposes. Any claim for attorney as shall allege ultimate facts which, if proven, would give rise to entitlement to the award of an attorney fee. Prior to hearing any issue as to the amount of disputed attorney fees or costs, the attorney shall file a verified petition setting forth with specificity the amount of time expended, costs advanced or incurred, and the benefit obtained together with all other allegations of fact pursuant to section 440.34, Florida Statutes. At the request of any party, or on the judge's own motion, the judge of compensation claims shall determine the procedure for the hearing and adjudication of any issues as to a disputed attorney fee and taxation of costs. fn Committee Notes fn 1988 Adoption. fn This rule formalizes and makes substantially uniform existing practice as to attorney-client contracts and attorney fees as those proceedings have evolved since the 1979 legislative reforms. Approval of any attorney client agreement by the deputy commissioner is discretionary and not mandatory. fn RULE 4.062. PAYMENT OF ATTORNEY FEES BY EMPLOYEE fn The judge of compensation claims shall hear any motion for attorney fees in the manner provided for a hearing on a claim for compensation. With respect to proceedings in which the fee is to be paid by the employee, the employee may waive a formal hearing before the judge of compensation claims and the judge of compensation claims may consider the motion ex parte, based on verified pleadings. No motion for attorney fees shall be granted by the judge of compensation claims unless it appears affirmatively that the provisions of these rules and of chapter 440, Florida Statutes, have been substantially complied with and that the employee has been advised as to those provisions. fn Committee Notes fn 1988 Adoption. fn It is intended that all motions under this rule be sworn to by the employee and contain a notarial jurat. fn RULE 4.065. MOTION PRACTICE fn (a) fn Substantive Motions. fn A motion relating to the adjudication of entitlement to benefits, including, but not limited to, motions to vacate orders for lump-sum advances, motions for advances under sections 440.20 (12)(c)2 and 440.20 (12)(d), Florida Statutes, appeals of administrative fines or penalties under section 440.106, Florida Statutes, motions for appointment of guardians, motions to appoint expert medical advisors under section 440.13, Florida Statutes, requests for imposition of sanctions under these rules, motions to disqualify a judge or a mediator, motions to recuse counsel, motions to correct the appellate record, and motions to appoint independent medical examiners under section 440.13, Florida Statutes, shall be handled in the manner as provided for a claim in rule 4.025. fn (b) fn Procedural Motions. fn (1) Procedural motions include, but are not limited to, motions to consolidate, motions related to discovery, motions to dismiss for lack of prosecution, motions to dismiss for lack of specificity, motions to amend pretrial stipulations, motions for a continuance, motions to compel, motions for protective orders, and motions in limine. Procedural motions shall be heard on not less than 5 days' written notice. The judge may require the moving party to serve written notice of the hearing on opposing counsel. No pretrial hearing shall be required. fn (2) A procedural motion shall set forth in detail the facts giving rise to the motion, its legal basis, and the specific relief sought. Any documents relied on should be specifically referenced and attached. fn (c) fn Contents. fn (1) All motions shall contain the following certificate of counsel: fn (A) The motion is made in good faith and not for the purpose of delay. fn (B) The opposing counsel has been contacted in an effort to resolve the matter without a hearing, and despite those efforts, the opposing counsel objects to the motion. fn (d) fn Emergency Motions. fn All emergency procedural motions shall be identified as such and shall identify the nature of the emergency including time constraints. Emergency procedural motions shall be heard promptly. fn (e) fn Response to Motions. fn A written response to a contested motion is not required. If a written response is made, it shall specifically state the basis for the objection. fn (f) fn Hearing Location. fn Unless the moving party obtains prior approval of the judge, all procedural motions shall be heard at the office of the judge. If the judge allows telephone appearances, the party wishing to appear by telephone shall be responsible to coordinate the appearance of counsel and other necessary participants and to notify the judge. fn (g) fn Notice of Hearing. fn Notices of hearing shall be prepared and served on the parties pursuant to rule 4.030. fn (h) fn Motion Hearing at Pretrial Hearing. fn Motions may be heard at pretrial hearing in accordance with rule 4.045. fn (i) fn Motions Seeking Affirmative Relief. fn Judges, at their own discretion, may treat any motion seeking affirmative relief or the adjudication of entitlement to any benefits in the manner provided for a claim or petition under these rules. fn (j) fn Motions to Dismiss. fn (1) In addition to meeting the requirements of subdivision (a), all motions to dismiss must state with particularity the basis for the motion. The judge shall enter an order on such motions without a hearing, unless good cause for the hearing is shown. fn (2) Notwithstanding the entry of a docketing order under rule 4.029, any motion to dismiss for lack of specificity must be filed pursuant to section 440.192 (5), Florida Statutes, and comply with the requirements of subdivisions (a) and (b) of this rule. The motion must be filed within 30 days after receipt of the petition or it is waived. fn (k) fn Motion to Receive Medical Records. fn All medical records of authorized treating health care providers relating to the claimant and subject accident shall be received into evidence upon proper motion served on the fn opposing party at the time of the pretrial hearing or no later than 30 days before the final hearing. Such records shall be served with the motion. fn Committee Notes fn 1995 Adoption. fn This rule clarifies existing procedure in various districts and defines procedural versus substantive motions that may require an evidentiary hearing. Replaces rule 4.140. fn The motion to receive into evidence the medical records of authorized treating health care providers may be contained within the Uniform Pretrial Stipulation, Pretrial Compliance Questionnaire, and Order. fn RULE 4.070. APPLICATION FOR HEARING fn An application for hearing concerning a claim made pursuant to chapter 440, Florida Statutes shall state concisely in separate numbered paragraphs the reasons for requesting hearings and the questions at issue or in dispute which the applicant expects the judge to hear and determine with sufficient particularity that the responding or opposing parties may be notified of the purpose of the hearing, including the issues to be heard and determined are specific benefit due and not paid. Application for the first hearing or trial in a cause shall be filed with the division at Tallahassee. On receipt of an application for hearing, all materials filed with or received by the division shall be incorporated in the file for forwarding to the appropriate judge of compensation claims who will conduct the hearing. All subsequent materials received or filed also shall be immediately forwarded to the judge of compensation claims. Applications for any hearings in the case shall be filed with the judge to whom the case has been assigned. A copy of the application shall be served on counsel for each party and a copy on any party not represented by counsel. Failure to serve a copy of the application as required shall be grounds for a continuance or cancellation of the hearing. fn Committee Notes fn 1979 Adoption. fn This replaces rule 7, 1977 W.C.R.P. It is derived substantially from section 440.25(3)(a), Florida Statutes (1979), which again emphasizes "the specific benefit due and not paid." This clearly points up one of the many differences between civil proceedings generally, and workers' compensation: [that] from the `Notice of Injury' a file is begun and maintained by the division in Tallahassee. As a deputy commissioner assumes supervision for the purpose of providing judicial-type services, that administrative file [in the division] provides, in part, the foundation for the file pertinent to the litigation. Even as the litigation proceeds, the administrative functions must be continued, hence a continuing relationship between the dual nature [of that file as] administrative/judicial. fn 1980 Amendment. fn This change would keep the division, the agency which is involved in various stages of the management of workers' compensation cases, apprised of the status of the case, and informed of the reason for the deputy's continued possession of the file. fn 1984 Amendment. fn Implements section 440.25(3)(a), Florida Statutes. fn RULE 4.075. PROSECUTION OF CLAIM AND PETITION FOR BENEFITS BEFORE JUDGE fn (a) fn Generally. fn To protect the interest of any party and to advance the proceedings, the judge may: fn (1) sever any issue; fn (2) continue a scheduled hearing as to any or all issues; fn (3) reserve jurisdiction of any issue; fn (4) dismiss any issue without prejudice, fn (5) refer any issue to the EAO in the event a petition filed by an unrepresented claimant is found to be nonspecific or a party has failed to exhaust the EAO administrative remedies; or fn (6) refer any issue to mediation. fn (b) fn Prosecution of Claim or Petition. fn After a final hearing has been set, all parties shall diligently prosecute or defend the claim or petition. fn (c) fn Continuances. fn (1) Continuances of hearings will not be freely granted and will be granted only upon a showing of good cause. fn (2) The judge may cancel or continue a trial on his or her own motion or on the motion of a party if the judge finds that the cancellation or continuance is for good cause and has not resulted from lack of diligence in the prosecution or defense of the petition or claim. fn (3) A request for a continuance shall be made by motion or stipulation of the parties and shall specify the reason that the continuance is necessary. fn (4) Unless otherwise ordered by the judge, continuance of a trial or pretrial hearing shall automatically extend the time provided for the completion of any subsequent act. fn (5) If there is a pretrial stipulation or pretrial order in place and the final hearing is continued, an additional pretrial hearing will not be set unless requested in writing by a party. fn (d) fn Voluntary Dismissal. fn A claim or petition may be dismissed by the claimant or petitioner without an order by filing a notice or stipulation of voluntary dismissal at any time before the final hearing begins, or during the final hearing before the claimant or petitioner rests by stating on the record such notice of voluntary dismissal. Unless otherwise stated in the notice or stipulation, the dismissal is without prejudice, except that a second notice of voluntary dismissal shall operate as an adjudication of denial of any claim or petition for benefits previously the subject of a voluntary dismissal. fn (e) fn Motion To Dismiss for Lack of Prosecution. fn (1) A motion to dismiss for lack of prosecution may be filed if it appears that no action has been taken on any claim or petition by request for hearing, filing of pleading, order of the judge, payment of compensation, provision of medical care, or otherwise, for a period of one year. fn (2) The judge shall serve notice of hearing on the parties by regular mail at their last known address. fn (3) The motion to dismiss shall be granted unless a party shows good cause why the claim or petition should remain pending. fn (f) fn Proceedings by Telephone. fn (1) The judge may conduct any proceedings permitted under these rules or under chapter 440, Florida Statutes, by telephone conference, provided a means of recording the proceedings is available, if requested by any party. fn (2) No live testimony, other than that of an expert witness as defined by the applicable statutes, shall be taken by telephone without the agreement of all parties. fn (3) In the event that trial testimony is taken by telephone, the oath shall be administered in the physical presence of the witness, by a notary public or officer authorized to administer oaths. A certificate of the notary public or officer, substantially the same as form 4.9105, shall be filed by the party offering the witness's trial testimony within 15 days. fn Committee Notes fn 1995 Adoption. fn This rule replaces and expands rule 4.110. Subdivision (d) is in response to the First District Court of Appeal pronouncements in fn Eastern Airlines v. Granese, fn 631 So.2d 365 (Fla. 1st DCA 1994), and Judge C.J. Kahn's suggestion in his concurring opinion in fn Perez v. Winn-Dixie, fn 639 So.2d 109 (Fla. 1st DCA 1994), that the Committee examine this subdivision to accurately reflect its intent that voluntary dismissals in workers' compensation matters conform to Florida Rule of Civil Procedure 1.420 (a)(1), as the Committee stated in its 1984 Committee Note to prior rule 4.110. fn RULE 4.080. NOTICE OF HEARING; ORDER OF JUDGE OF COMPENSATION CLAIMS fn (a) fn Notice of Hearing. fn The judge of compensation claims shall hold a hearing within 90 days after the filing of an application for hearing, and shall serve the parties and counsel of record at their last known addresses, with at least 15 days' notice by regular mail. The notice shall state with particularity the questions at issue or in dispute that the judge will heal and determine. Service of a notice of healing shall be complete upon fn mailing. Unless otherwise specified in the notice of hearing, the judge may consider and determine all issues pending as of the date of the hearing. fn (b) fn Setting of Hearing. fn Judges of compensation claims, in their discretion, may set hearing singly at a time certain, or in the aggregate using dockets in the form provided in forms 4.908 and 4.909. fn (c) fn Order. fn The order of the judge of compensation claims shall set forth findings of fact, conclusions of law, and the judge's determination of the claim or other ruling. The order shall be signed by the judge of compensation claims and shall include a certificate of service to all parties and counsel of record. fn Committee Notes fn 1979 Adoption. fn This replaces rule 8, 1977 W.C.R.P. fn It, too, is derived substantially from section 440.25(3)(a), Florida Statutes (1979). Note that the deputy shall give the notice. fn 1980 Amendment. fn 8. (a) Suggestions have been made to remove the requirement that notice to the parties of a hearing be sent by certified mail. The Rules Committee of the Workers' Compensation Section is of the opinion that the requirement that the hearing notice be sent by certified mail should be retained for two reasons. In the first instance, the statute, section 440.25 (3)(a), Florida Statutes, requires notice by certified mail, and, secondly, this provision is viewed as one which provides at least a minimum level of procedural due process. fn 8. (b) The portion of this rule which the rules committee of the section recommends be removed was in conflict with the wording of rule 14, which has been transplanted, in toto, to rule 8(b). fn 1984 Amendment. fn Conforms hearing notice requirements to section 440.25 (3)(a), Florida Statutes, as amended to delete requirement of certified mail service, and provides clarification of time periods involved to the effect that minimum 15 days' notice is measured from the date notice is mailed. fn 1988 Amendment. fn This rule and accompanying forms provide a standard form for the notice of hearing. In the alternative, a hearing docket system is provided for in recognition of the adoption of that procedure in some districts. The provisions of subdivision (b) are new. The balance of the rule reflects the 1984 revision with minor changes in wording for clarity. fn RULE 4.085. FINAL HEARING fn (a) fn Notice. fn The judge shall give 30 days' notice of the final hearing to all parties by mail. The notice of the final hearing may be set forth in the pretrial order accompanying the notice of mediation, notice of pretrial hearing, and pretrial order, or may be issued separately by the judge. fn (b) fn Form and Service of Notice. fn The notice shall state clearly the questions at issue or in dispute that the judge will hear. fn (c) fn Attendance. fn (1) Unless excused by the judge, counsel for all parties shall attend the final healing in person. fn (2) Except as authorized under the Florida Rules of Civil Procedure, the claimant shall attend the final hearing in person. As provided under rule 4.075, a witness may appear by telephone, provided communication equipment is available at the location of the final hearing and prior arrangements have been made for administering the oath to the witness. fn (3) Witnesses appearing by telephone must be identified at the time of the pretrial hearing or specifically designated in the witness list or pretrial stipulation. fn (d) fn Witnesses. fn (1) Only those witnesses listed in the pretrial stipulation or in the witness list served no later than 30 days before the final hearing will be allowed to testify. fn (2) Witnesses may be added after the 30-day witness deadline only by stipulation of the parties or by approval by the judge. fn (e) fn Admissibility of Evidence. fn (1) The judge shall rule promptly on a question of the admissibility of evidence. fn (2) If an objection is made and not ruled on by the judge, the ruling shall be presumed to be adverse to the party making the objection. fn (f) fn Proffers. fn Evidence that has been offered but ruled inadmissible may be proffered but shall be clearly identified as such by the judge. fn (g) fn Exhibits. fn (1) The contents of the division file with respect to a claim or petition shall not be admissible evidence as such, absent the stipulation of all parties, but individual portions of the file shall be admitted if admissible under the rules of evidence. fn (2) Legible copies may be substituted for original documents when reasonably necessary. fn (3) Voluminous or cumbersome exhibits shall not be received into evidence unless their use is unavoidable. fn (h) fn Posthearing Evidence. fn Except in extraordinary circumstances and only on specific motion, posthearing evidence, including exhibits and depositions, will not be allowed. However, the judge on his or her own motion may consider posthearing evidence. fn Committee Notes fn 1995 Adoption. fn In most circumstances the petitioner/claimant will appear at the final hearing, particularly if his or her testimony is needed. However, under Florida Rule of Civil Procedure 1.330 (a)(3), the deposition of a party may be used at trial under certain circumstances. This rule is intended to conform to Florida Rule of Civil Procedure 1.330 (a)(3). fn RULE 4.090. DISCOVERY fn (a) fn Depositions. fn Depositions of witnesses or parties, residing, within or without the state, may be taken and used in connection with proceedings under chapter 440, Florida Statutes, either on the order of the judge of compensation claims or at the instance of any party or prospective party to such proceeding. For good cause shown, the judge of compensation claims may require the taking of a deposition by telephone. fn (b) fn Production of Documents and Entry on Land. fn The parties shall be subject to discovery procedures dealing with the production of records and other tangible things, and entry on land or other property for inspection or other purposes within the scope of discovery, including but not limited to all hospital and medical reports pertaining to the industrial accident, all rehabilitation reports, all records pertaining to the claimant's average weekly wage at the time of the industrial accident or earnings made subsequent to the industrial accident, and a transcript of any recorded statement of a party. The parties shall have 30 days to serve a written response after service of any request under this rule. The judge of compensation claims, for good cause shown, may enlarge or shorten the time allowed for compliance with this rule. fn (c) fn Production of Documents from NonParties. fn The parties also may seek the production of documents and other tangible things, within the scope of discovery, for inspection and copying, from a person who is not a party pursuant to applicable Florida Rules of Civil Procedure. fn (d) fn Jurisdiction. fn The judge of compensation claims shall have jurisdiction to take appropriate action to compel discovery, including the imposition of sanctions, and, as circumstances warrant, may enlarge or shorten the applicable time for complying with discovery. fn (e) fn When Discovery May Be Had. fn Discovery under this rule may be had prior to the institution of a claim, if the claimant is represented by an attorney, or after the filing of a claim, in the same manner and for the same purposes as provided in the Florida Rules of Civil Procedure. fn (f) fn Other Discovery. fn Interrogatories, requests for admission, and other forms of discovery not authorized by this rule shall not be used or permitted in workers' compensation proceedings. fn (g) fn Surveillance. fn The evidence of any investigator, adjustor, or other witness in the nature of surveillance shall be subject to discovery when such evidence will be used at trial, provided the party intending to use fn such evidence is first given a reasonable opportunity to depose the party or witness who is the subject of the surveillance. fn Committee Notes fn 1979 Adoption. fn This replaces rule 9, 1977 W.C.R.P. fn It is derived substantially from section 440.30, Florida Statutes (1979). fn 1984 Amendment. fn Subdivisions (b) through (f) are new and formalize additional forms of discovery already widely used in workers' compensation proceedings. This rule specifically declines to adopt interrogatories or requests for admission as unduly cumbersome and contrary to the overriding policy consideration for the expeditions resolution of an injured worker's rights. Although discovery is generally intended to be self-administrating it is subject to the supervision of the deputy commissioner. fn Stephens v. Southern Furniture Transports, Inc., 420 So.2d 904 (Fla.1st DCA 1982). This rule does not modify and is consistent with the powers and authority conferred upon the deputy commission pursuant to section 440.33, Florida Statutes. fn 1988 Amendment. fn Subdivision (g) of this rule is intended to conform to fn Dodson v. Persell, 390 So.2d 704 (Fla. 1980). fn RULE 4.095. EMERGENCY CONFERENCES fn (a) fn Generally. fn An emergency conference may be held if there is a bona fide emergency involving the health, safety, or welfare of an employee as provided for in section 440.25 (4)(h), Florida Statutes. fn (b) fn Requests. fn A request for an emergency conference shall be handled in the same manner as provided for a procedural motion in rule 4.065. A written request for an emergency conference shall be filed with the judge and served on the parties in accordance with rule 4.030. It shall set forth in detail the facts giving rise to the request, its legal basis, the factual or medical basis for the claim that there is a bona fide emergency involving the health, safety, or welfare of an employee, and the specific relief sought. Any documents relied upon should be specifically referenced and attached. fn (c) fn Certificate of Counsel. fn The request shall contain the certificate of counsel that: fn (1) the request is made in good faith and not for the purpose of delay; fn (2) the opposing party or counsel, if represented, has been contacted in an effort to resolve the matter without a hearing, and despite those efforts a hearing is required; and fn (3) to the best of counsel's knowledge, information, and belief, formed after inquiry reasonable under the circumstances, a bona fide emergency exists involving the health, safety, or welfare of the employee. fn (d) fn Notice of Emergency Conference. fn The judge may require the appearance of the parties and counsel without written notice for such an emergency conference. fn (e) fn Attendance. fn Parties, counsel, and witnesses may appear by telephone if telephone equipment is available. fn (f) fn Orders. fn An emergency conference under this rule may result in the entry of an order or the rendering of an adjudication by the judge that shall be limited to those issues and relief sought in the request. fn Committee Notes fn 1995 Adoption. fn [This rule is intended to provide some structure, notice, and procedure in requesting emergency conferences that may result in the entry of an order or the rendering of an adjudication by the judge of compensation claims. fn This rule replaces rule 4.112, which allowed compulsory advisory conferences. fn RULE 4.100. PRETRIAL PROCEDURE fn (a) fn Generally. fn Judges of compensation claims may, on their own motion, or shall on the motion of any party to the action, hold a pretrial conference, at which the parties shall; fn (1) state and simplify the claims, defenses, and issues; fn (2) make appropriate amendments to the claims and defenses; fn (3) stipulate and admit to such facts and documents as will avoid unnecessary proof; fn (4) present, examine, and mark for identification, all exhibits. Impeachment and rebuttal exhibits need not be revealed; fn (5) furnish the opposing party the names and addresses of all witnesses. Impeachment witnesses, and rebuttal witnesses thereto, need not be revealed; fn (6) exchange all available written reports of experts when expert opinion is to be offered at trial. The reports should clearly disclose the expert opinion and its basis on all subjects on which the expert will testify. If stipulated into evidence, the parties shall present the reports to the judge of compensation claims to be so marked. The parties shall consider and determined a limitation on the number of expert witnesses; fn (7) estimate trial time; and fn (8) consider and determine such other matters as may aid in the disposition of the cause. fn (b) fn Notice. fn The judge of compensation claims shall give the parties at least 15 days' notice of the pretrial conference. If a party or the party's attorney fails to attend the conference without good cause, the judge of compensation claims may dismiss the claim or strike the defenses, or take such other action as may be authorized by law or these rules. The judge of compensation claims may cancel the pretrial conference on submission of a written pretrial stipulation. The judge of compensation claims may conduct the pretrial conference by telephone at the request of any party, or on the judge's own motion, provided all parties are represented by counsel. fn (c) fn Record. fn The judge of compensation claims shall record the pretrial conference by stenographic or electronic means at the request of any party, or by a written stipulation signed by the parties. fn (d) fn Pretrial Order. fn At the request of any party, the judge of compensation claims shall promptly enter an order reciting the action taken at the pretrial conference, the amendments allowed to the claims and defenses, and the agreements made by the parties about any of the matters considered, and limiting the issues for trial to those not disposed of by admissions or stipulations of the parties. The judge of compensation claims shall serve the order on the attorneys for the parties and on any party not represented by counsel. The order shall control the subsequent course of the action unless the judge of compensation claims modifies it to prevent injustice. The order on the pretrial conference may be in letter form unless a formal order is requested by any party. fn Committee Notes fn 1979 Adoption. fn This replaces rule 10, 1977 W.C.R.P., but is substantially the same. fn 1984 Amendment. fn Provides that a party has the right to a pretrial conference upon request. Deletes requirement of notice of pretrial by order. fn RULE 4.105. EXPEDITED HEARINGS fn (a) fn Generally. fn If a petition filed in accordance with section 440.192, Florida Statutes, involves a claim or petition of $5,000 or less, excluding attorney fees and costs, it may be considered for resolution under section 440.25 (4)(j), Florida Statutes. fn (b) fn Application for Expedited Hearings. fn On written application of one party or by stipulation, any claim or petition filed in accordance with section 440.192, Florida Statutes, may be resolved under section 440.25 (4), Florida Statutes. The application for expedited hearing shall be substantially the same as form 4.9091. A copy of this application shall be filed with the judge and served on all interested parties. fn (c) fn Motion to Dispense. fn Any motion to dispense with expedited hearing shall comply with rule 4.065 and must be based on compelling evidence that the claim or petition is not appropriate for expedited resolution. fn (d) fn Expedited Docketing and Notice. fn The judge shall serve written notice of the hearing on the parties not less than 45 days before the hearing. fn (e) fn Discovery. fn The parties shall have at least 30 days to conduct discovery, which shall be completed 15 days before the hearing. fn (f) fn Pretrial Outline. fn At least 15 days before the hearing, a pretrial outline shall be filed with the judge and served on all parties. The following shall be attached: fn (1) fn Statement of the Facts. fn The statement shall include references to the specific pages in the deposition testimony of witnesses as well as a suggestion of the expected testimony of those witnesses who will be called to testify at the hearing. fn (2) fn Memorandum of Law. fn The memorandum shall include relevant case citations and copies of the cases cited. fn (3) fn Attachments. fn A complete composite of the records of the medical advisor appointed by the judge or the division, any independent medical examination (IME) physicians, and any other authorized providers shall be attached. There shall also be attached any depositions or other documentary items on which a party will rely to establish the case. The pages of the composite shall be numbered and the composite shall be preceded by an abstract referencing and synthesizing those portions of the records on which the filing party relies. No additional records, depositions, or documentary evidence will be admitted at the time of the hearing. fn (g) fn Witness and Subpoenas. fn At the final hearing, the parties must arrange to have all witnesses present or available to testify promptly at the time and place noticed. Subpoenas will be issued on request of the parties or their counsel. If any party or legally subpoenaed witness fails to appear at the time and place set for the hearing, sanctions under rule 4.150 may be imposed or punitive actions authorized under sections 440.32 and 440.33, Florida Statutes, may be initiated. fn (h) fn Final Hearing Procedure. fn The final hearing will not exceed 30 minutes. The employer/carrier may be represented by an adjuster or other qualified representative. All previously scheduled final hearings and pretrial conferences shall be canceled. fn (i) fn Posthearing Evidence. fn Posthearing evidence shall be considered in the same manner as provided in rule 4.085. fn Committee Notes fn 1995 Adoption. fn This rule codifies the procedure to follow when requesting a 30-minute expedited hearing as authorized by section 440.25 (4)(j), Florida Statutes, for claims of $5,000 or less, or if stipulated to by the parties. fn RULE 4.110. PROSECUTION OF CLAIM BEFORE JUDGE OF COMPENSATION CLAIMS fn (a) fn Prosecution of Claim. fn When a trial has been set by a judge of compensation claims, all parties shall diligently prosecute and defend the claim. Judges of compensation claims may cancel or continue a trial on their own motion or on the motion of a party if they find that the cancellation or continuance is for good cause which has not resulted from lack of diligence in the prosecution or defense of the claim. A notice of voluntary dismissal is without prejudice, except that a second notice of voluntary dismissal by the claimant operates as an adjudication of denial of any claim for the same benefit or benefits previously the subject of a voluntary dismissal. fn (b) fn Dismissal of Claim or Petition. fn Any claim, or any petition to modify, in which it affirmatively appears that no action has been taken by request for hearing, filing of pleadings, order of the judge of compensation claims payment of compensation, provision of medical care, or otherwise for a period of one year, is subject to dismiss for lack of prosecution. On motion to dismiss filed by any interest party, or on request of the judge of compensation claims before whom the action is pending, the file shall be forwarded to the appropriate judge of compensation claims who shall dismiss the claim or petition, after service of notice to the parties by regular mail at their last known address and opportunity for hearing, unless party should remain pending. fn Committee Notes fn 1979 Adoption. fn This replaces rule 11, 1977 W.C.R.P. fn The 1977 rule was the result of extensive debate and revision, and the committee did not see need for substantial revision. fn 1980 Amendment. fn Deletion of the words "after filing in rule 11(b) allows the dismissal of a state claim after any two year period of inactivity. The change will make this rule consistent with rule 1.420(e) of the Florida Rules of Civil Procedure. fn 1984 Amendment. fn (a) Conforms workers' compensation procedure with Florida Rule of Civil Procedure 1.420 (a)(1). Voluntary dismissal of the same claim or claim for the same benefits is with prejudice and operates as a denial of the claim for those benefits. fn (b) Conforms nonprosecution time period one year. fn RULE 4.111. PROCEEDINGS BY TELEPHONE fn The judge of compensation claims may conduct any proceeding permitted under these rules or under chapter 440, Florida Statutes, by telephone conference provided no live testimony, other than that of an expert witness as defined by the applicable statutes, is taken without the agreement of all parties and provided a means of recording the proceedings is available if requested by any party. fn Committee Notes fn 1988 Adoption. fn This rule is adapted from rule 2.071, Florida Rules of Judicial Administration, to which reference may be made for purposes of construction. fn RULE 4.112. EMERGENCY CONFERENCES fn The judge of compensation claims may require the appearance of the parties and counsel on less than 15 days' written notice as otherwise required by these rules and by chapter 440, Florida Statutes, only to consider the reasonableness and medical necessity of proposed medical treatment when there is a bona fide emergency involving the health or safety of an employee. The parties may agree to consider other issues at an emergency conference. An emergency conference under this rule shall be advisory in nature, shall not constitute a hearing for any purpose, and shall not result in the entry of an order or the rendering of an adjudication by the judge of compensation claims. No other emergency conference or hearing is permitted by these rules. fn Committee Notes fn 1988 Adoption. fn This rule is intended to allow for a compulsory, advisory conference with the deputy commissioner only as to issues relating to the reasonableness and medical necessity of proposed emergency medical treatment. fn RULE 4.115. ORDERS fn (a) fn Generally. fn (1) The order of the judge shall set forth findings of fact, conclusions of law, and the judge's determination of the claim or other ruling. fn (2) The order shall be signed by the judge and shall include a certificate of service to all parties and counsel of record. fn (b) fn Amending or Vacating Order. fn (1) A judge may, at his or her own discretion or pursuant to a motion for rehearing, vacate or amend an order not yet final pursuant to section 440.25, Florida Statutes. fn (2) Grounds for vacating an order may include circumstances in which it appears to the judge that due consideration of a motion for rehearing may not be practicable before the order becomes final. fn (c) fn Effect of Appeal. fn Nothing in these rules shall be construed to interfere with the judge's jurisdiction to either approve settlements or correct clerical errors, as specified under rule 4.160. fn (d) fn Rule Nisi. fn Pursuant to an order of a court having jurisdiction of a proceeding to enforce an order of the judge, the judge may conduct such hearings, consider such evidence, and enter such orders as may be necessary to determine any specific sums due pursuant to the order that is the subject matter of the rule nisi proceeding. fn Committee Notes fn 1995 Adoption. fn This rule incorporates former rules 4.080 (c) and 4.141 (b)-(d). fn Subdivision (b) codifies the long-established practice in workers' compensation litigation: A judge of compensation claims retains jurisdiction over an order that has not fn yet become final. The rule implicitly adopts the majority view in fn Drexel Properties, Inc. v. Brown, fn 443 So.2d 150 (Fla.1st DCA 1983), giving the deputy commissioner wide latitude in determining whether to amend or vacate an order. fn RULE 4.130. AGREEMENTS fn No agreement or stipulation shall be valid unless: (1) in writing and signed by the parties or their attorneys, or (2) dictated on the record. Any agreement or stipulation under this rule may be expressly relied on by the judge of compensation claims in any proceeding, unless a party seeks to be relieved of the agreement or stipulation for good cause shown. The judge of compensation claims may abrogate any stipulation which appears to be manifestly contrary to the evidence on due notice to the parties; however the judge of compensation claims need not inquire beyond the stipulation or agreement. fn Committee Notes fn 1979 Adoption. fn This replaces rule 13, 1977 W.C.R.P. fn RULE 4.131. SETTLEMENT OF PROSPECTIVE BENEFITS fn In any proceeding in which the parties undertake to compromise or release the prospective entitlement of the employee to any class of benefits pursuant to section 440.20 (12), Florida Statutes: fn (a) The parties shall submit their agreement in writing executed by all attorneys of record and by the employee. fn (b) The employee shall acknowledge the agreement and its material provisions under oath in writing or before the judge of compensation claims. fn (c) An agreement under this rule shall set forth the terms, conditions, and consideration for the settlement together with all material facts necessary for approval of the settlement pursuant to section 440.20(12), Florida Statutes. fn (d) Prior to the approval of any agreement under this rule, the parties and their attorneys shall submit to the judge of compensation claims for including in the division file all evidence in their possession which is material to the consideration and disposition of the settlement agreement. fn (c) The order of the judge of compensation claims approving or disapproving the proposed settlement shall set forth findings of fact and conclusions of law support the approval or disapproval of the proposed settlement and may be in substantially the form provided in these rules. fn Committee Notes fn 1988 Adoption. fn The rule intends to codify and standardize existing practice as to washout settlements. The accompanying forms are substantially those presently in general use. fn RULE 4.140. MOTION PRACTICE fn (a) fn Procedural Motions. fn Any matter relating to procedure or discovery may be raised by motion before the judge of compensation claims. The motion shall be filed with the judge of compensation claims having jurisdiction of the industrial accidents, who will promptly hear and decide the issues raised by the motion after giving not less than 5 days' written notice to all parties. Motions may be heard at any pretrial conference, provided the motion was filed and served not less than 5 days prior to the date of the pretrial conference. fn (b) fn Motions Seeking Affirmative Relief. fn Judges of compensation claims, in their discretion, may treat any motion seeking affirmative relief or the adjudication of entitlement to any benefit in the manner provided for a claim for benefits under these rules. fn Committee Notes fn 1988 Adoption. fn Subdivision (a) of this rule is intended to create an expedited procedure for the disposition of motions relating to discovery and other preliminary matters not involving the adjudication of issues properly raised by claim or notice of defenses. Subdivision (b) is intended to control the adjudication of substantive motions, such as motions for change of physicians, to suspend payment or provision of benefits, and the like. fn RULE 4.141. MOTION FOR REHEARING ; VACATING OR AMENDING ORDER OF JUDGE OF COMPENSATION CLAIMS; RULE NISI fn (a) fn Rehearing. fn Any party may file with the judge of compensation claims a motion for rehearing directed to an order not yet final by operation of section 440.25, Florida Statutes. Such a motion shall state with specificity the grounds on which it is based. The filing of such motion does not toll either the time within which an order becomes final or the time within which an appeal may be filed. fn (b) fn Amending, Vacating Orders. fn At the judge of compensation claims' discretion, an order not yet final by operation of section 440.25, Florida Statutes, may be either vacated or amended at either the judge of compensation claims' own initiative or pursuant to a motion for rehearing. Grounds for vacating an order may include circumstances in which it appears; to the judge of compensation claims that due consideration of a motion for rehearing may not be practicable within the time remaining under section 440.25, Florida Statutes. fn (c) fn Effect of Appeal. fn Nothing in this rule shall be construed to interfere with the judge of compensation claims' jurisdiction to either approve of settlements or correct clerical errors, as specified under rules 4.160(h)(3) and 4.165(g). fn (d) fn Rule Nisi. fn Pursuant to an order of a court having jurisdiction of a proceeding to once an order of the judge of compensation claims, the judge may conduct such hearings, consider such evidence, and enter such orders as may be necessary to determine any specific sums due pursuant to the order which is the subject matter of the rule nisi proceeding. fn (a) fn Generally. fn A motion for rehearing shall state specifically the grounds on which it is based and should not be used to reargue issues already determined. A motion for rehearing may be filed only within 20 days from the date of an order not yet final under section 440.25, Florida Statutes. fn (b) fn Purpose. fn The purpose of the motion shall be limited to: fn (1) call attention to typographical, technical, and scrivener's errors; fn (2) challenge rulings that were outside the scope of the issues presented; or fn (3) seek clarification in matters of law or fact that the judge overlooked or misapprehended. fn (c) fn Effect on Timeliness. fn A motion for rehearing does not toll the time within which either an order becomes final or an appeal may be filed. It is the moving party's responsibility to contact the judge's office to schedule a hearing on the motion. fn Committee Notes 1984 Adoption. Acosta Roofing Company v. Gillyard, 402 So.2d 1321 Dade American Hospital Supply v. Perez, 417 So.2d 296 Drexel Properties, Inc. v. Brown, 443 So.2d 150 1995 Amendment. fn Subdivisions (b), (c), and (d) were moved to new rule 4.115, Orders. New subdivision (c) was added. fn RULE 4.142. AGREEMENTS OR STIPULATIONS fn (a) fn Scope. fn Agreements or stipulations not involving settlements under section fn 440.20 (11), Florida Statutes, shall comply with this rule. fn (b) fn Generally. fn No agreement or stipulation shall be enforceable unless it is: fn (1) in writing and signed by the parties or their attorney; fn (2) dictated on the record; or fn (3) in the case of a settlement agreement resulting from a conference pursuant to section 440.191 (2)(c), Florida Statutes, approved in writing by the docketing judge. fn (c) fn Form. fn All agreements or stipulations submitted to a judge for approval and entry of an order shall include a detailed statement of the issues in dispute and how the issues were resolved, including a description of the benefits provided. fn (d) fn Reliance. fn Any agreement or stipulation under this rule may be expressly relied on by the judge in any proceeding, unless a party seeks to be relieved of the agreement or stipulation for good cause shown. fn (e) fn Abrogation. fn The judge may abrogate any stipulation that appears to be manifestly contrary to the evidence on due notice to the parties; however, the judge need not inquire beyond the stipulation or agreement. fn Committee Notes fn 1995 Adoption. fn This replaces and clarifies rule 4.130. Subdivision (c) requires that an order approving an agreement or stipulation under this rule also include a detailed statement of the issues, their resolution, and the benefits to be provided as reflected in the agreement or stipulation. fn RULE 4.143. SETTLEMENT UNDER SECTION 440.20 (11), FLORIDA STATUTES fn (a) fn Scope. fn This rule applies in any proceeding in which the parties undertake to compromise or release any class of benefits pursuant to section 440.20 (11), Florida Statutes. fn (b) fn Uniform Stipulation Forms. fn The parties shall submit their agreement in writing executed by all attorneys of record and the employee. The parties will use the standard forms published by the Office of the Judges of Compensation Claims, or the equivalent, when submitting an agreement. fn (c) fn Required Documents. fn A joint petition seeking the approval of a lump-sum settlement under section 440.20 (11), Florida Statutes, shall be filed with the judge's office along with: fn (1) a stipulation using the standard forms published by the Office of the Judges of Compensation Claims, or the equivalent, signed by the claimant, all attorneys of record, unrepresented parties, or representatives of the employer/carrier; fn (2) an affidavit of the claimant in which the claimant shall acknowledge the agreement and its material provisions under oath in writing or before the judge, unless all relevant information is incorporated in the verified stipulation; fn (3) a maximum medical improvement report, documentation of the permanent impairment rating, information concerning the need for future medical care, and other essential medical information; fn (4) any other evidence in the possession of the parties and their attorneys that is material to the consideration and disposition of the settlement; fn (5) a notice letter to the employer as required under section 440.20 (11)(b), Florida Statutes; fn (6) an attorney-fee data sheet; fn (7) an attorney's affidavit seeking approval of an attorney fee and specifying the statutory factors forming the basis for a variance, if the requested fee exceeds the statutory guidelines under sections 440.34 (1)(a)-(1)(h), Florida Statutes; fn (8) the notice(s) of denial and the report to the chief judge for settlements under section 440.20 (11)(a), Florida Statutes. fn (d) fn Orders. fn The order of the judge approving or disapproving the proposed settlement shall set forth findings of fact and conclusions of law to support the approval or disapproval of the proposed settlement, and may be in the form provided in these rules. fn Committee Notes fn 1995 Adoption. fn This rule replaces rule 4.131 because of the 1993 amendments to washout settlements under section 440.20 (11), Florida Statutes. The intent of the rule is to codify and provide statewide uniformity as to washout settlement practice. The accompanying forms are substantially those presently in general use. fn RULE 4.144. PAYMENT OF ATTORNEY FEES AND COSTS fn (a) fn Generally. fn On written request for hearing, the judge shall hear any claim for attorney fees and taxable costs in the manner provided for a hearing on a petition. fn (b) fn Payment of Undisputed Attorney Fees and Costs by Claimant. fn (1) The claimant and his or her attorney may jointly move for the judge to approve the payment of an attorney fee and reimbursement of costs pursuant to a contract of representation by a stipulated motion substantially in the form provided by these rules. fn (2) The claimant may waive a formal hearing before the judge and the judge may consider the motion ex parte based on verified pleadings. fn (3) No motion for attorney fees shall be granted by the judge unless it appears affirmatively that the provisions of these rules and of chapter 440, Florida Statutes, have been substantially complied with and that the employee has been advised as to those provisions. fn (c) fn Payment of Undisputed Attorney Fees and Costs by Employer/Carrier/Servicing Agent. fn The employee and the employer/carrier/servicing agent may stipulate to the payment of attorney fees and costs and submit the stipulation for the judge's approval pursuant to rule 4.115. fn (d) fn Payment of Disputed Attorney Fees and Costs. fn (1) Any claim for attorney fees shall allege the statutory basis for the claim and may be subject to a pretrial hearing under these rules. However, if entitlement to attorney fees or costs has been adjudicated or stipulated, no pretrial hearing shall be held unless ordered by the judge. fn (2) Unless otherwise ordered at the pretrial hearing, the verified petition shall be served on all parties 30 days before the scheduled fee hearing and shall include: fn (A) a statement of the facts relied upon in support of the petition pursuant to section 440.34, Florida Statutes, including an opinion as to a reasonable fee amount; fn (B) the statutory and legal basis relied upon in support of the petition; fn (C) except for hearings to determine the value of appellate services, a recitation of all benefits secured for the claimant through the attorney's efforts, including projected future benefits reduced to present value; fn (D) a detailed chronological listing of all time devoted to the claim, and; fn (E) a detailed list of all taxable costs advanced or incurred. fn (e) fn Service of Response. fn Within 20 days after the verified petition is served, the opposing party or parties shall respond to the petition and shall include a recitation of all matters controverted in the verified petition. fn (f) fn Bifurcation. fn If both entitlement and the amount of the fee are contested, the hearing may be bifurcated. fn (g) fn Evidence on Amount. fn With the agreement of the parties, testimony as to the amount of the fee may be submitted in affidavit form. Otherwise, such testimony must be presented by deposition or at the fee hearing as provided in rule 4.085. fn Committee Notes fn 1995 Adoption. fn This rule replaces subdivisions (b) and (c) of rules 4.061 and 4.062, and codifies and standardizes the procedure for adjudication of disputed attorney-fee matters. fn RULE 4.150. SANCTIONS (a) fn Generally. fn briefs fn claims, defenses, fn denial of oral argument, dismissal of proceedings, fn ; fn , fn or fn , fn ; fn of compensation claims shall fn may fn These sanctions are in addition to any sanctions available to the judge pursuant to section 440.33, Florida Statutes. fn (b) fn Signature. fn Every pleading, written motion, and other paper shall be signed by the attorney of record or, if the party is not represented, by the party. Each paper shall state the signer's address and telephone number, if any. Except when otherwise specifically provided by rule or statute, pleadings need not be verified. An unsigned paper shall be stricken unless omission of the signature is corrected promptly after being called to the attention of the attorney or party. fn (c) fn Representations to Judge. fn By presenting to the judge, whether by signing, filing, submitting, or later advocating, a pleading, written motion, or other paper, an attorney or unrepresented party is certifying to the best of the person's knowledge, information, and belief, formed after inquiry reasonable under the circumstances, that: fn (1) it is not being presented for any improper purpose, such as to harass or to cause unnecessary delay or needless increase in the cost of litigation; fn (2) the claims, defenses, and other legal contentions therein are warranted by existing law or by a nonfrivolous argument for the extension, modification, or reversal of existing law or the establishment of a new law; fn (3) the allegations and other factual contentions have evidentiary support or, if specifically so identified, are likely to have evidentiary support after a reasonable opportunity for further investigation or discovery; fn (4) the denials of factual contentions are warranted on the evidence or, if specifically so identified, are reasonably based on a lack of information or belief. fn (d) fn Determination of Violation. fn If, after notice and a reasonable opportunity to respond, the judge determines that subdivision (c) has been violated, the judge may, subject to the conditions stated below, impose an appropriate sanction on the attorneys or parties who have violated subdivision (c) or are responsible for the violation. fn (e) fn How Initiated. fn (1) A motion for sanctions under this rule shall be made separately from other motions or requests and shall describe the specific conduct alleged to violate subdivision (c). It shall be served as provided in rule 4.030, but shall not be filed with or presented to the judge unless the challenged paper, claim, defense, contention, allegation, or denial is not withdrawn or appropriately corrected within 21 days after service of the motion (or such other period as the judge may prescribe). If warranted, the judge may award to the party prevailing on the motion the cost of the proceeding and attorney fees incurred in presenting or opposing the motion. fn (2) On his or her own initiative, the judge may enter an order describing the specific conduct that appears to violate subdivision (c) and directing an attorney or party to show cause why it has not violated subdivision (c) with respect thereto. fn (f) fn Nature of Sanctions. fn (1) A sanction imposed for violation of this rule shall be limited to what is sufficient to deter repetition of such conduct or comparable conduct by others similarly situated. Subject to the limitations in this subdivision and in subdivision (d), the sanction may consist of, or include, directives of a nonmonetary nature, or a penalty pursuant to section 440.20 or 440.24, Florida Statutes; or, if imposed on motion and warranted for effective deterrence, an order directing payment to the movant of some or all of the reasonable attorney fees and other costs incurred as a direct result of the violation. If the judge determines that any proceedings were maintained or continued frivolously, the cost of the proceeding, including attorney fees, shall be assessed against the offending attorney. Penalties, fees, and costs awarded under this provision may not be recouped from the party. fn (2) Monetary sanctions may not be awarded against a represented party for a violation of subdivision (c)(2). fn (3) Monetary sanctions may not be awarded on the judge's initiative unless the judge issues an order to show cause before a voluntary dismissal or settlement of the claim made by or against the party that is, or whose attorneys are, to be sanctioned. fn (g) fn Order. fn When imposing sanctions, the judge shall describe the conduct determined to constitute a violation of the rule and explain the basis for the sanction imposed. If a penalty is assessed against an attorney pursuant to section 440.24, Florida Statutes, or this rule, the judge shall forward a copy of the order assessing the penalty to the appropriate grievance committee acting under the jurisdiction of the supreme court. fn Committee Notes 1979 Adoption. 1995 Adoption. fn This rule extensively amends the prior rule. It is adopted from Federal Rule of Civil Procedure 11, and the intent is to create a uniform procedure to consider requests for sanctions relating to violations of section 440.32, Florida Statutes. fn RULE 4.155. DISQUALIFICATION OR RECUSAL OF JUDGES fn (a) Any motion for disqualification of a judge shall be made and determined pursuant to Florida Rule of Judicial Administration 2.160. fn (b) Upon the entry of an order of disqualification or the voluntary recusal by a judge, the chief judge shall promptly reassign the matter to another judge to conduct all further proceedings. In the absence of any written objection filed with the chief judge within 7 days of the order reassigning the matter, the chief judge may, in the interest of the prompt administration of justice, transfer venue of the cause of action. fn Committee Notes fn 1995 Adoption. fn This rule adopts Florida Rule of Judicial Administration 2.160, for the procedure to disqualify or recuse a judge of compensation claims and permits reassignment by the chief judge. fn PART C fn III. fn MEDIATION PROCEEDINGS RULE 4.300. GENERAL PROVISIONS fn (a) fn Generally fn Mediation in workers' compensation matters is a process authorized by section 440.25, Florida Statutes, in which a mediator acts to encourage and facilitate the resolution of a workers' compensation dispute between two or more parties by assisting those parties in reaching a mutually acceptable and voluntary agreement, thereby dispensing with the need for judicial determination. fn (b) fn Purpose. fn The purpose of this part is to provide the procedures that shall govern mediations of workers' compensation matters. fn (c) fn Privileged and Confidential Communications. fn (1) Any information from the files, reports, case summaries, or other communications or materials, oral or written, relating to a mediation conference obtained by any person participating in mediation is privileged and confidential and may not be disclosed without written consent of the interested parties involved in the mediation conference. fn (2) Each party to a mediation conference has a privilege during and after the mediation conference to refuse to disclose and prevent another from disclosing communications made during the mediation conference, whether or not the disputed issues are successfully resolved. This subdivision shall not be construed to prevent or inhibit the discovery or admissibility of any information that is otherwise subject to discovery or that is admissible under an applicable law or rule of procedure, except that any conduct or statement made during a mediation conference or in negotiations concerning the mediation conference are inadmissible in any proceedings under chapter 440, Florida Statutes. fn (3) In no event shall the mediator be subpoenaed, be called to testify, or give a statement or deposition to resolve any matter or disclose any communications or conduct made during the mediation conference. fn (d) fn Discovery. fn Discovery may continue notwithstanding an order of referral to fn mediation or pending a mediation conference unless otherwise ordered by the presiding judge. fn (e) fn Effect on Petitions or Claims. fn Mediation shall not preclude or be cause for delay in the prosecution of a petition or claim nor prevent the scheduling and attendance at hearings thereon as required by section 440.25, Florida Statutes, unless otherwise ordered by the presiding judge. fn Committee Notes fn 1995 Adoption. fn Subdivision (c) is from former rule 4.360 (e), subdivision (d) is from former rule 4.350 (d), and subdivision (e) is from former rule 4.340 (e). fn RULE 4.310. MANDATORY MEDIATION fn (a) fn Initial Mandatory Mediation. fn Except as hereinafter provided, an initial mandatory mediation conference is required to be held concerning every petition filed under section 440.192, Florida Statutes, that survives dismissal after review by a docketing judge under section 440.45 (3), Florida Statutes, or a motion to dismiss filed under section 440.192 (5), Florida Statutes. fn (b) fn Notice and Date of Mandatory Mediation Conference. fn (1) Within 7 days after a petition is filed under section 440.192, Florida Statutes, but in no event more than 7 days from the presiding judge's receipt of the petition that survives a dismissal, the judge, or the mediator if the judge so designates, shall notify all interested parties of the date, time, and location of the initial mandatory mediation conference. The notice may be served personally or by mail upon the interested parties. fn (2) The mediation conference shall be held within 21 days after a petition is filed under section 440.192, Florida Statutes, but if continued or rescheduled as hereinafter provided, it shall be held and completed no later than 10 days before any scheduled pretrial hearing. fn (c) fn Waiver of Initial Mandatory Mediation Conference. fn A mandatory mediation conference may be waived only by order of the chief judge after the filing with the presiding judge of a motion to waive the initial mandatory mediation conference no later than 3 days before the scheduled conference. fn (d) fn Mediator. fn The initial mandatory mediation conference required to be held under section 440.25 (1), Florida Statutes, shall be conducted by a mediator or adjunct mediator employed by the chief judge under section 440.25 (3), Florida Statutes. fn (e) fn Mediator's Report. fn Within 10 days following the conclusion of the mediation conference, the mediator shall file a written report with the presiding judge as to whether any of the issues in dispute are resolved. If an impasse was declared the mediator shall so report without comment or recommendation. If the parties reach an agreement, it shall be filed with the presiding judge in accordance with rule 4.142. fn Committee Notes fn 1995 Adoption. fn This rule codifies the procedure for mandatory mediation required by section 440.25, Florida Statutes, for every petition for benefits. fn Subdivision (c) also permits filing the motion to waive with the presiding judge who shall then forward the motion to the chief judge for consideration. fn Subdivision (d) contemplates that the mandatory mediation shall be conducted by the mediator or adjunct mediator employed by the chief judge under section 440.25 (3), Florida Statutes, without charge to the parties. Any substitution of the mediator requires approval by the presiding judge. fn RULE 4.330. GENERAL PROVISIONS fn (a) fn Definitions. fn The following definitions apply to workers' compensation mediation, unless the context or subject matter otherwise requires: fn (1) "Mediation" is a process authorized by section 440.25(3), Florida Statutes, whereby a mediator acts to encourage and facilitate the resolution of a workers' compensation dispute or claim between 2 or more parties by assisting the parties, in reaching a mutually acceptable and voluntary agreement, thereby dispensing with the need for judicial determination by trial. fn (2) "Mediator" is the person appointed by the chief judge in accordance with the provisions of section 440.25 (3)(b)1, Florida Statutes, to conduct a mediation conference. The mediator is a member in good standing of The Florida Bar, known as a general master, special master, or a judge of compensation claims. A judge of compensation claims who acts as a mediator shall not act as a presiding judge on the same case. fn (3) "Mediation conference" is an informal nonadversarial negotiation or settlement conference attended by the interested parties and supervised and conducted by a mediator. fn (4) "Mediator agreement" also known as a mediation settlement agreement, means a mutually acceptable and voluntary written or recorded agreement reached by the parties at a mediation conference with the assistance of a mediator, resolving completely or partially a workers' compensation dispute or claim. fn (5) "Impasse" is the parties' inability to reach a mutually acceptable and voluntary agreement as to any matter at the mediation conference. fn (6) "Chief judge" means the chief judge of compensation claims appointed by the governor, serving in the Department of Labor and Employment Security, pursuant to section 440.45 (3), Florida Statutes. fn (7) "Judge" means a judge of compensation claims pursuant to section 440.45, Florida Statutes. A presiding judge is the judge having jurisdiction of the industrial accident and to whom the claim has been assigned. fn (8) "Parties" means the employee, claimant, employer, and carrier. fn (b) fn Purpose. fn The purpose of these rules, adopted and promulgated pursuant to the legal authority of the Supreme Court of Florida, is to provide the procedures that shall govern the mediation of workers' compensation disputes and claims. fn RULE 4.340. REQUEST FOR OR REFERRAL TO SUBSEQUENT fn MEDIATION Application fn Request fn for Subsequent fn Mediation. A mediation conference may be requested by any interested party, at any time following a claim up to 60 days prior to a hearing schedules pursuant to section 440.25 (3)(c), Florida Statutes. A request shall be made by the filing of an application for mediation conference with one of the following; fn (1) The division, if filed simultaneously with a claim for benefits and/or application for hearing. fn (2) The presiding judge or general master. fn An order requiring the parties to attend a mediation conference shall be entered by a presiding judge upon the application. fn (1) Notwithstanding attendance at a mandatory mediation conference, any interested party may request a mediation conference at any time following the filing of a petition under section 440.192, Florida Statutes, or any other claim subject to adjudication by a judge. The request shall be made on or before 45 days prior to a final hearing scheduled pursuant to section 440.25 (4)(a), Florida Statutes. A request shall be made by the filing of a motion for mediation conference with the presiding judge. fn (2) After considering the merits of the request, the presiding judge may enter an order referring the matter to mediation and requiring the parties to attend a mediation conference. An order upon such request may be entered without a hearing, unless good cause for a hearing is shown. fn Referral by Presiding Judge or by Stipulation. also fn petition or any fn therein fn a party's motion, fn conference fn hearing fn in accordance with rule 4.100(a)(8) fn , if the judge finds mediation may aid in the disposition of the matter before trial. fn Motion to Dispense With or Defer Subsequent fn Mediation. (1) fn 1 fn 1 fn A fn same fn and the moving party verifies that further mediation would be of no benefit in resolving the matter; fn 2 fn B fn 3 fn C fn (2) fn prior to fn before fn for fn of the fn . fn conference and shall serve fn N fn n fn the fn shall be provided to fn on fn (d) fn Denial of Mediation by Mediator. fn A mediator may deny a request for mediation if the mediator determines the matter or issues to be inappropriate for mediation. Within 15 days of the receipt of application for mediation conference or an order of referral to mediation, the mediator shall notify the parties of the recommendation of denial and refer the matter to the presiding judge for the entry of an order approving or disapproving the denial or, at the judge's discretion, scheduling a hearing on the mediator's recommendation. fn (e) fn Effect on Claims for Benefits. fn Mediation shall not preclude or delay the prosecution of a claim for benefits nor prevent the filing of an application for hearing and the scheduling and attendance at hearings thereon as required by section 440.25, Florida Statutes. fn Committee Notes fn 1995 Amendment. fn This rule extensively amends the prior rule and affords the parties the opportunity to request or stipulate to a subsequent mediation in the event they reached an impasse at the initial mandatory mediation conference. fn RULE 4.350. APPOINTMENT OF MEDIATOR AND fn SCHEDULING MEDIATION CONFERENCE FOR SUBSEQUENT MEDIATION fn Appointment or Selection of Mediator. On receipt of an application for mediation conference from the division the chief judge shall assign the matter to the appropriate mediator. However, if the referral to mediation is pursuant to an order based on a motion, stipulation, or pretrial hearing, then the order shall designate the appropriate mediator, previously selected and assigned by the chief judge to the district having jurisdiction of the industrial accident. fn (1) Within 10 days of the order of referral to mediation entered pursuant to rule 4.340, the parties may stipulate to the selection of a member of The Florida Bar to act as a mediator who, in the opinion of the parties and the presiding judge, is otherwise qualified by training or experience to mediate all or some of the issues in the pending workers' compensation claim or petition. fn (2) If the parties cannot agree on a mediator within 10 days of the order of referral, the judge shall appoint a mediator or adjunct mediator employed by the chief judge pursuant to section 440.25 (3), Florida Statutes, in the district in which the matter is pending. fn (b) fn Mediator Fees. fn (1) Mediations conducted by a mediator or adjunct mediator employed by the chief judge under section 440.25 (3), Florida Statutes, shall be at no cost to the parties. fn (2) When the mediator selected by the parties and approved by the judge is one other than a mediator or adjunct mediator employed by the chief judge under section 440.25 (3), Florida Statutes, the amount and method of payment of the mediator fees shall be agreed upon between the parties, or their attorneys, and the mediator. fn b fn c fn Notice of Mediation Conference ; Order. fn receipt by the appropriate mediator fn receiving fn of an application for mediation conference or fn under rule 4.340, fn A notice of mediation conference shall be substantially in the same form as the notice of hearing form in rule 4.908. The first mediation conference shall be held within 45 days of the filing of an application for mediation fn conference or entry of an order of referral but no sooner than 15 days from the date of the notice or order scheduling such mediation conference. fn The mediation conference ordered under rule 4.340 shall be held no sooner than 7 days from the date of the notice scheduling the mediation conference unless otherwise agreed by the parties. fn c fn d fn Completion of Mediation; Continuances; Adjournments. within 30 fn 10 fn of the first mediation conference fn before the final hearing fn on stipulation of the parties fn or the judge. fn mediation fn mediation fn (d) fn Discovery. fn Discovery may continue throughout mediation. fn Committee Notes fn 1995 Amendment. fn This rule extensively amends the prior rule and is fashioned after Florida Rule of Civil Procedure 1.720 (f). It allows the parties to stipulate to the selection of a private mediator to conduct a subsequent mediation. The stipulation also must reflect the amount and method of payment of the mediator fees. fn RULE 4.360. MEDIATION PROCEDURES fn CONFERENCE fn Attendance in Mediation. 4.111 fn 4.075, fn Unless stipulated by the parties or relieved by order of the presiding judge, fn A fn a fn at a mediation conference fn or petitioner, fn an insured or fn servicing agent/carrier fn Sanctions for Failure to Appear. including payment of the mediator fees, if any. fn Counsel of Record. The mediation shall control the mediation and the procedures to be followed in mediation. fn (d) fn Communication with Parties. fn The mediator may meet and consult privately with any party or parties or their counsel. fn (e) fn Privileged and Confidential Communications. fn (1) Any information from the files, reports, case summaries, mediator's notes, or other communications or material or written relating to a mediation conference obtained by any person participating in mediation is privileged and confidential and may not be disclosed without written consent of the interested parties involved in the mediation conference. fn (2) Each party to a mediation conference has a privilege during and after the conference to refuse to disclose and prevent another from disclosing communications made during the mediation conference, whether or not the disputed issues are successfully resolved. fn This subdivision shall not be construed to prevent or inhibit the discovery or admissibility of any information that is otherwise subject to discovery or that is admissible under an applicable law or rule of procedure, except that any conduct or statement made during a mediation conference or in negotiations concerning the conference is inadmissible in any proceeding under chapter 440, Florida Statutes. fn (3) In no event shall the mediator be subpoenaed, called to testify, or give a deposition to resolve any claim or disclose any communications or conduct made during the mediation conference. fn Committee Notes fn 1995 Amendment. fn This rule extensively amends the prior rule. fn RULE 4.361. AUTHORITY AND DUTIES OF MEDIATORS fn (a) fn Authority of Mediator. fn (1) The mediator shall at all times be in control of the mediation and the procedures to be followed. fn (2) The mediator may meet and consult privately with any party or parties or their counsel during the mediation. fn (3) The mediator shall make a good-faith effort to schedule the mediation conference at a time that is convenient for all parties, all attorneys, and the mediator. In the absence of agreement, the mediator shall schedule the date for the mediation conference. fn (4) The mediator shall have discretion to allow any party to appear at the mediation conference by telephone. fn (b) fn Duties of Mediator. fn The mediator shall inform the parties at the beginning of the mediation conference: fn (1) of the process of mediation; fn (2) that the mediator is an impartial facilitator, and is there to assist the parties in reaching, not to force them to reach, a voluntary settlement; fn (3) of the differences between mediation and a final hearing before the presiding judge; fn (4) if applicable, of the costs of the mediation; fn (5) that the mediation process is consensual in nature, and the parties retain their right to a final hearing if they do not reach agreement; fn (6) of the privileged and confidential nature of communications made during the mediation under rule 4.300 (c); fn (7) that any agreement reached at the mediation conference will be by mutual consent of the parties, reduced to writing, and subject to the approval of the presiding judge if necessary. fn (c) fn [Disclosure. fn The mediator has a duty to be impartial and to advise all parties of any circumstances bearing on possible bias, prejudice, or partiality. fn (d) fn Guide for Mediator Conduct. fn A mediator's conduct in discharging the professional responsibility in mediating workers' compensation matters should be guided by the Standards of Professional Conduct found in Part II of the Florida Rules for Certified and Court-Appointed Mediators as approved by the Supreme Court of Florida. fn (e) fn Matters beyond Mediator's Competence. fn A mediator shall decline appointment, withdraw, or request technical assistance when the mediator decides that a matter is beyond the mediator's competence. fn Committee Notes fn 1995 Adoption. fn This rule is intended to codify the authority and duties of a workers' compensation mediator and adopts the Standards of Professional Conduct for Certified and Court-Appointed Mediators. fn RULE 4.370. CONCLUSION OF MEDIATION Impasse. It is the duty of the mediator to timely determine when mediation is no longer helpful or viable and that an impasse exists, or that mediation should end. fn Mediation Agreement. and their attorneys, fn 4.130 fn 4.142 and shall be filed with the presiding judge. fn and may enter an order approving the mediation agreement. fn Enforcement of Agreement. 440.24 Agreement to Enter into Section 440.20 (1 2 fn 1 fn , Florida Statutes, Settlement. of the claimant to fn to the employee of fn 440.202 fn 1 fn first fn 4.131 fn 4.143 fn aforesaid statutory provision fn requirements of section 440.20 (11), Florida Statutes. fn RULE 4.380. DISQUALIFICATION MEDIATOR Procedure. shown fn presiding fn chief fn replacement fn substitute mediator fn Disclosure by Mediator fn im fn Nothing in this rule shall preclude mediators from disqualifying themselves or refusing any assignment. fn Committee Notes fn 1995 Amendment. fn Editorial changes. fn PART D fn IV fn . FORMS FORM 4.901. CAPTION AND STYLE OF PLEADINGS DIVISION OF WORKERS' COMPENSATION fn Committee Notes 1988 Adoption. FORM 4.902. ATTORNEY'S CERTIFICATE OF SERVICE OF EX PARTE ORDER (bar no.) fn Committee Notes 1988 Adoption. FORM 4.903. CONTRACT OF REPRESENTATION, POWER OF ATTORNEY, TRUST AGREEMENT, AND MOTION Form of Agreement for Accidents Occurring before October 1, 1989. s fn STATE OF _______________________ fn COUNTY OF ______________________ fn BEFORE ME, the undersigned authority, personally appeared ___________, to me well known to be the person described in the foregoing Contract of Representation, Power of Attorney, Trust Agreement, and Motion and acknowledged to me that (s)he executed the same for the purpose contained therein. fn IN WITNESS WHEREOF, I have hereunto set my hand and official seal this ____ day of ______________, 19 __. fn ________________________________ NOTARY PUBLIC fn My Commission Expires: fn STATE OF FLORIDA COUNTY OF ............ fn The foregoing contract was acknowledged before me by ..... (name of employee/claimant) ....., who identified this instrument as ..... (name of instrument) ....., who signed the instrument willingly, and who is fn Personally Known OR Produced Identification Type of Identification Produced fn (Signature of Notary Public — State of Florida) fn (Print, Type, or Stamp Commissioned Name of Notary Public) fn Form of Agreement for Accidents Occurring on or after October 1, 1989 and before January 1, 1994. fn s fn STATE OF fn COUNTY OF fn BEFORE ME, the undersigned authority, personally appeared __________, to me well known to be the person described in the foregoing Contract of Representation, Power of Attorney, Trust Agreement, and Motion and acknowledged to me that (s)he executed the same for the purpose contained therein. fn IN WITNESS WHEREOF, I have hereunto set my hand and official seal this ____ day of ______________, 19 __. fn ________________________________ NOTARY PUBLIC fn My Commission Expires: fn STATE OF FLORIDA COUNTY OF ............ fn The foregoing contract was acknowledged before me by ..... (name of employee/claimant) ....., who identified this instrument as ..... (name of instrument) ....., who signed the instrument willingly, and who is fn Personally Known OR Produced Identification Type of Identification Produced fn (Signature of Notary Public — State of Florida) fn (Print, Type, or Stamp Commissioned Name of Notary Public) fn (c) fn Form of Agreement for Accidents Occurring on or after January 1, 1994. fn CONTRACT OF REPRESENTATION, POWER OF ATTORNEY, TRUST AGREEMENT, AND MOTION fn I, the undersigned employee, hereby retain and employ the undersigned as my attorney to represent me with respect to the industrial accident and injury described above in any workers' compensation claim I may have, under the following terms and conditions: fn 1. AUTHORIZATION. I authorize my attorney to act on my behalf in prosecuting my workers' compensation claim. My attorney is authorized to make such investigations, undertake such legal proceedings, and expend such monies on my behalf as my attorney may deem necessary. fn 2. ATTORNEY FEES. I agree to pay to my attorney a reasonable attorney fee for services rendered with respect to my workers' compensation claim. I request that my employer and its carrier (or servicing agent) make all payments of workers' compensation indemnity benefits payable jointly to me and my attorney in care of my attorney at the attorney's address. fn I authorize my attorney to retain in trust from my indemnity benefits to secure the payment of my attorney fees and costs: fn 20% of the first $5,000 of all benefits secured; 15% of the next $5,000 of all benefits secured; 10% of all benefits secured thereafter until 10 years after the filing of a petition/claim; 5% of all benefits secured after the expiration of the 10 year term; fn although the attorney fee may be greater or less than the sums retained in trust depending on the amount of time my attorney expends in the prosecution of my claim, the difficulty, novelty, or complexity of my case, and the amount ultimately paid or awarded. fn THE JUDGE OF COMPENSATION CLAIMS (WORKERS' COMPENSATION JUDGE) WILL MAKE THE FINAL DETERMINATION AS TO THE AMOUNT OF AND MY ATTORNEY'S ENTITLEMENT TO AN ATTORNEY FEE. fn To the extent the money held in trust exceeds my attorney fees and costs, or if all or part of my attorney fees and costs are paid by my employer and its carrier (or servicing agent), the balance held in trust will be returned to me. fn Under some circumstances, my employer and its carrier (servicing agent) may be found liable to pay all or a part of my attorney fees and court costs. Those circumstances are when: fn a. my employer or its carrier has denied that I had an on-the-job accident or injury; fn b. my employer or its carrier has refused to provide me with medical care and I am not at that time entitled to any other benefits; fn c. my employer or its carrier files a Notice of Denial with the Division of Workers' Compensation for the benefits claimed. fn I understand that the recovery of attorney fees and costs in addition to my benefits may require a separate proceeding for which I may incur additional costs and attorney fees. If my employer or its carrier is required to pay my attorney a fee for any benefits my attorney obtains for me, I will not be obligated to pay an additional fee for obtaining that benefit. fn 3. COSTS. I agree to reimburse my attorney for all costs associated with the prosecution of my claim to the extent that these costs are not recovered from the employer and its carrier (servicing agent), regardless of the outcome of my claim. My attorney may use any monies held in trust under this contract to pay any costs incurred on my behalf. fn 4. EMPLOYEE RESPONSIBILITIES. I agree to promptly and fully advise my attorney as to any developments or information that may have a bearing on my workers' compensation claim and to keep my attorney advised at all times as to my whereabouts and correct mailing address. fn I will promptly attend any appointments made for me by my attorney and will submit to any medical or vocational examinations or evaluations arranged by my attorney. fn I will not discuss my case with any person not specifically authorized by my attorney. fn I agree to cooperate fully with my attorney. fn I understand that my attorney expressly relies on the truthfulness of all statements made by me and that I may be subject to criminal prosecution if I make false or misleading statements in connection with my workers' compensation claim. fn I UNDERSTAND THAT MY ATTORNEY MAY TERMINATE THIS CONTRACT OF REPRESENTATION IF I DO NOT FULLY COMPLY WITH THIS AGREEMENT. fn 5. ATTORNEY'S RESPONSIBILITIES. The undersigned attorney agrees to diligently pursue the employee's workers' compensation claim and to keep the employee fully informed as to this claim. The attorney accepts the trust provisions of this agreement and will account to the employee as to any monies received, expended, or held on the employee's behalf at the employee's request. fn 6. LIMITED POWER OF ATTORNEY. The undersigned employee does hereby make constitute, and appoint the undersigned attorney as the employee's agent and attorney-in-fact to act in the employee's name, place, and stead to negotiate the employee's workers' compensation benefit checks or drafts only for the purposes of this contract. fn 7. APPROVAL OF CONTRACT OF REPRESENTATION BY JUDGE OF COMPENSATION CLAIMS. I understand that this agreement is binding upon signing. I authorize my attorney to submit this agreement to the judge of compensation claims for the judge's approval. fn Having read and signed this contract of representation and having discussed its provisions with my attorney, the undersigned employee jointly with the undersigned attorney moves that the judge of compensation claims approve this contract of representation. The employee waives notice of hearing and waives a formal hearing before the judge of compensation claims with respect to the approval of this contract of representation. fn EMPLOYEE fn WITNESS fn WITNESS fn STATE OF FLORIDA COUNTY OF ............ fn The foregoing contract was acknowledged before me by ..... (name of employee/claimant) ....., who identified this instrument as ..... (name of instrument) ....., who signed the instrument willingly, and who is fn Personally Known OR Produced Identification Type of Identification Produced fn (Signature of Notary Public — State of Florida) fn (Print, Type, or Stamp Commissioned Name of Notary Public) fn ATTORNEY FOR THE EMPLOYEE fn Committee Notes 1988 Adoption. 1992 Amendment. FORM 4.904. ORDER APPROVING CONTRACT OF REPRESENTATION AND DIRECTING PAYMENT OF BENEFITS , fn That t fn T fn that fn That t fn T fn 4.061(a) fn 4.023 fn That t fn T fn shall fn That t fn T fn Committee Notes 1988 Adoption. FORM 4.905. MOTION FOR EX PARTE PAYMENT OF ATTORNEY FEES AND COSTS : fn : fn : fn : fn : fn : fn : fn : Amount: (bar numbor) fn STATE OF ________________________ COUNTY OF _______________________ BEFORE ME, the undersigned authority, personally appeared _____________, to me well known to be the person described in the foregoing motion and acknowledged to me that (s)he executed the same for the purposes containing therein. fn IN WITNESS WHEREOF, I have set my hand and seal this ___ day of ______, 19__. fn NOTARY PUBLIC My Commission Expires: fn STATE OF FLORIDA COUNTY OF ............ fn The foregoing contract was acknowledged before me by ..(name of employee/claimant) ....., who identified this instrument as ..(name of instrument) .., who signed the instrument willingly, and who is fn Personally Known OR Produced Identification Type of Identification Produced fn (Signature of Notary Public — State of Florida) fn (Print, Type, or Stamp Commissioned Name of Notary Public) fn Committee Notes fn 1995 Amendment. fn Editorial changes. fn FORM 4.906. ORDER APPROVING ATTORNEY FEES AND COSTS that fn t fn T] fn a] fn A] fn Committee Notes fn 1995 Amendment. fn Editorial changes. fn FORM 4.907. ORDER ON LEAVE fn MOTION fn TO WITHDRAW AS COUNSEL LEAVE fn MOTION fn That a fn A fn Committee Notes fn 1995 Amendment. fn Editorial changes. fn FORM 4.9075. PETITION FOR BENEFITS fn (a) Petition for Benefits for Accidents Occurring on or before December 31, 1993. fn PETITION FOR BENEFITS FOR ACCIDENTS OCCURRING ON OR BEFORE DECEMBER 31, 1993 Under the Florida Workers' Compensation Law Florida Department of Labor and Employment Security Division of Workers' Compensation For Assistance Call 1-800-342-1741 COMPLETE ALL APPLICABLE SECTIONS BEFORE FILING TWO COPIES WITH THE DIVISION fn SECTION A: INJURED EMPLOYEE INFORMATION: (If occupational disease or prolonged exposure, use the last date of injurious exposure, or the date disability began as Date of Accident. fn Only one accident date may be addressed per petition form.) fn Number and Street fn Suite or Apt. # fn City fn State fn Zip Code fn SECTION B: PETITIONER INFORMATION. Complete only if different from injured employee information. fn Number and Street fn Suite or Apt. # fn City fn State fn Zip Code fn Number and Street fn Suite or Room fn City fn State fn Zip Code fn Number and Street fn Suite or Room fn City fn State fn Zip Code fn 2. Detailed description of injury and cause. fn A. What part of your body was injured? fn B. Briefly describe what caused the injury. For example, were you struck by some object? Did you fall? Did you strain yourself? Were you exposed to some toxic substance or some job-related disease? fn SECTION F: DESCRIPTION OF JOB, WORK RESPONSIBILITIES, AND THE WORK BEING PERFORMED WHEN INJURY OCCURRED. fn SECTION G: PETITION FOR BENEFITS. The above-named (circle one) (injured employee), (surviving spouse, child(ren)), (parents, brothers, sisters), (medical provider), (or other affected party) petitions the judge of compensation claims for an order requiring the employer/carrier/servicing agent (E/C) (E/SA) to provide the following benefits: fn * * *SPECIAL NOTE: If the injured employee seeks medical benefits only, so indicate. If the petition is for death benefits under section 440.16, Florida Statutes, items 1 through 4 of this section should be disregarded. fn This petition is for medical benefits only ______. (yes or no). fn 1. Jurisdiction: The judge has jurisdiction over the parties and the subject matter of this petition. fn 2. Employee Assistance and Ombudsman Office (EAO) unable to resolve dispute. The subject matter of this petition was presented to the EAO created under section 440.191, Florida Statutes, in a good-faith effort to resolve the disagreements between the parties. The Request for Assistance was dated ___/___ /___. Despite these efforts, the matters were not resolved for one of the following reasons: fn (A) The informal dispute resolution process has been concluded, fn (B) The EAO has considered the matter and waived further action, fn (C) The parties were unable to resolve the dispute within 30 days after the request for assistance was made to the EAO, fn (D) The petition includes a claim for medical benefits and the employer has elected to provide such benefits under a managed care plan and is exempt from EAO consideration, fn (E) The dispute is subject to the terms of a collective bargaining agreement between the petitioner and the employer and is exempt from EAO consideration under section 440.211, Florida Statutes. fn 3. Maximum medical improvement (MMI). The injured employee (has) (has not) reached MMI. According to Doctor __________________, MMI was reached on ______, 19__. fn 4. Character of disability. The (injury) (injuries) occasioned by the events described above (has) (have) adversely affected the injured employee's capacity to earn in the same or any other employment the wages that he or she was receiving at the time of the injury. fn Specifically; the injury prevents the injured employee from: fn (Briefly describe below how the injury or occupational disease limits or prevents the injured employee from earning wages equal to the preinjury wages.) fn 5. fn Benefits claimed due and not provided. fn The (employer) (E/C) (E/SA) (has) (have) failed to provide the following benefits, which are in default and are presently ripe, due, and owing. (Check appropriate items.) fn (A) (1) Temporary total disability benefits from _____ to _____ at a compensation rate of $ _________ per week. fn (2) Temporary total disability benefits, under section 440.15 (2)(b), Florida Statutes (1979) or (1990) (circle appropriate date), from the date of the accident to _____. (Not to exceed 6 months.) fn (B) Temporary partial disability benefits from _____ to _____ at a compensation rate of $ _____ per week. fn (C) Impairment benefits due under section 440.15 (3)(a), Florida Statutes (1979) or (1990) $ _______. fn (1) The permanent impairment due to the injury is ______% of the whole body under the (AMA) (Minnesota) (Division) Guides. fn (2) These benefits are based on: fn (a) Permanent impairment due to the total loss of use of (body part affected.) fn (b) Permanent impairment due to amputation of (body part amputated after July 1, 1990.) fn (c) Permanent impairment due to the loss of 80% vision of either eye after correction. fn (d) Serious facial injury or head disfigurement. fn (D) Wage-loss benefits payable under section 440.15 (3)(b), Florida Statutes (1979) or (1990) from _____ to _____ at a rate of $ _______ per week. If the petitioner had earnings during the foregoing period of time; attach a list of the earnings on a biweekly basis or attach wage-loss request forms. fn (E) Permanent total disability under section 440.15 (1), Florida Statutes, from __________ to the present and continuing at a rate of $ ______ per week. These benefits are in default and are presently ripe, due, and owing. fn (F) Death benefits payable under section 440.16, Florida Statutes. fn (G) Correction of AWW and resulting compensation rate. Basis: fn (H) Medical expenses incurred for treatment of the employee's injury as provided under section 440.13 (2), Florida Statutes. The employee has specifically requested the payment of the charges, but the (employer) (E/C) (E/SA) (has) (have) failed, refused, or neglected to do so within a reasonable time. The following medical charges have not been paid (for numerous unpaid charges, a schedule in the following format may be attached): fn Name of Provider fn Number and street fn City, State, and Zip Code fn Date of treatment fn Amount due fn Date of treatment fn Amount due fn Date of treatment fn Amount due fn Name of Provider fn Number and street fn City, State, and Zip Code fn Date of treatment fn Amount due fn Date of treatment fn Amount due fn Date of treatment fn Amount due fn The employee has previously specifically requested the treatment, but the (employer) (E/C) (E/SA) (has) (have) failed, refused, or neglected to provide the treatment within a reasonable time. fn (Type or nature of medical treatment sought). fn (Justification for such medical treatment). fn (J) Medically necessary (professional) (nonprofessional) attendant care (performed) (to be performed) at the direction of a physician. The employee has previously specifically requested the attendant care, but the (employer) (E/C)(E/SA) (has) (have) failed, refused, or neglected to provide the care within a reasonable time. fn (Type or nature of medically necessary attendant care sought). fn (Justification for such attendant care). fn (K) Transportation and/or mileage costs $ ___________. fn (L) Rehabilitative temporary total compensation under section 440.491 (6)(b), Florida Statutes, from _____ to _____ at a rate of $ _________ per week. In support thereof, the injured employee further states as follows: fn (1) The employee has reached MMI. fn (2) As authorized under section 440.491 (6)(a), Florida Statutes, the division has approved the injured employee for training and education to obtain suitable gainful employment and is receiving such training and education. fn (3) (Optional) In addition to the temporary total compensation referenced above, the injured employee also required temporary residence at or near the facility or institution(s) providing training and education which is located more than 50 miles away from the employee's customary residence. fn (M) Attorney fees and costs under section 440.34 (3)(a)-(d), Florida Statutes. The statutory basis for the fee is: fn (N) Statutory penalties and interest: fn (1) Statutory penalty on past-due indemnity benefits. $ _______ fn (2) Statutory interest on all past-due benefits. $ ______ fn SECTION H: TOTAL DENIAL OF COMPENSABILITY OR OTHER ISSUE NOT REFERENCED ABOVE. fn 1. The employer/carrier/servicing agent has denied the compensability of the claim. fn 2. Give a specific explanation of any other issues the judge should consider in connection with the benefits claimed in this petition that were not referenced above. fn SECTION I: CERTIFICATE OF PETITIONER OR PETITIONER'S ATTORNEY (SECTION 440.192 (4), FLORIDA STATUTES) AND PETITIONER'S ATTESTATION (SECTION 440.105 (7), FLORIDA STATUTES). fn (print or type name of petitioner) fn (print or type name of petitioner's attorney) that a good-faith effort was made to resolve the dispute and that (he) (she) was unable to resolve the dispute with the employer/carrier/servicing agent. In accordance with section 440.192 (1), Florida Statutes, a copy of this petition for benefits has been served by certified mail on the injured worker's employer and the employer's carrier, and the original and one copy on the Division of Workers' Compensation in Tallahassee on ______, 19__. The petitioner further attests that (he) (she) has reviewed, understands, and acknowledges the following notice: Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information is guilty of a felony of the third degree. fn Signature of Petitioner fn Signature of Attorney for Petitioner .....(address)......... .....(telephone number)....... Florida Bar No.......... fn THE ORIGINAL AND ONE COPY OF THIS PETITION MUST BE FILED WITH: fn Division of Workers' Compensation 2728 Centerview Dr., Suite 220, Forrest Building Tallahassee, FL 32399-0685 fn (b) fn Petition for Benefits for Accidents Occurring on or after January 1, 1994. fn PETITION FOR BENEFITS FOR ACCIDENTS OCCURRING ON OR AFTER JANUARY 1, 1994 Under the Florida Workers' Compensation Law Florida Department of Labor and Employment Security Division of Workers' Compensation For Assistance Call 1-800-342-1741 COMPLETE ALL APPLICABLE SECTIONS BEFORE FILING TWO COPIES WITH THE DIVISION fn SECTION A: INJURED EMPLOYEE INFORMATION: (If occupational disease or prolonged exposure, use the last date of injurious exposure, or the date disability began as Date of Accident. fn Only one accident date may be addressed per petition form.) fn Number and Street fn Suite or Apt. # fn City fn State fn Zip Code fn SECTION B: PETITIONER INFORMATION. Complete only if different from injured employee information. fn Number and Street fn Suite or Apt. # fn City fn State fn Zip Code fn SECTION C: EMPLOYER INFORMATION. fn Number and Street fn Suite or Room fn City fn State fn Zip Code fn SECTION D: CARRIER INFORMATION. fn Number and Street fn Suite or Room fn City fn State fn Zip Code fn SECTION E: DESCRIPTION OF INJURY. fn Briefly describe what caused the injury. For example, were you — struck by some object? Did you fall? Did you strain yourself? Were you exposed to some toxic substance or some job-related disease? fn SECTION F: DESCRIPTION OF JOB, WORK RESPONSIBILITIES, AND THE WORK BEING PERFORMED WHEN INJURY OCCURRED. fn SECTION G: PETITION FOR BENEFITS. The above-named (circle one) (injured employee), (surviving spouse, child(ren)), (parents, brothers, sisters), (medical provider), (or other affected party) petitions the judge of compensation claims for an order requiring the employer/carrier/servicing agent (E/C) (E/SA) to provide the following benefits: fn * * * SPECIAL NOTE: If the injured employee seeks medical benefits only, so indicate. If the petition is for death benefits under section 440.16, Florida Statutes, items 1 through 4 of this section should be disregarded. fn This petition is for medical benefits only . (yes or no). fn 1. Jurisdiction: The judge has jurisdiction over the parties and the subject matter of this petition. fn 2. Employee Assistance and Ombudsman Office (EAO) unable to resolve dispute. The subject matter of this petition was presented to the EAO created under section 440.191, Florida Statutes, in a good-faith effort to resolve the disagreements between the parties. The Request for Assistance was dated / / . Despite these efforts, the matters were not resolved for one of the following reasons: fn (A) The informal dispute resolution process has been concluded, fn (B) The EAO has considered the matter and waived further action, fn (C) The parties were unable to resolve the dispute within 30 days after the request for assistance was made to the EAO, fn (D) The petition includes a claim for medical benefits and the employer has elected to provide such benefits under a managed care plan and is exempt from EAO consideration, fn (E) The dispute is subject to the terms of a collective bargaining agreement between the petitioner and the employer and is exempt from EAO consideration under section 440.211, Florida Statutes. fn 3. Maximum medical improvement (MMI). The injured employee (has) (has not) reached MMI. According to Doctor , MMI was reached on , 19 . fn 4. Character of disability. The (injury) (injuries) occasioned by the events described above (has) (have) adversely affected the injured employee's capacity to earn in the same or any other employment the wages that he or she was receiving at the time of the injury. fn Specifically; the injury prevents the injured employee from: fn (Briefly describe below how the injury or occupational disease limits or prevents the injured employee from earning wages equal to the pre-injury wages.) fn 5. Benefits claimed due and not provided. The (employer) (E/C) (E/SA) (has) (have) failed to provide the following benefits, which are in default and are presently ripe, due, and owing. (Check appropriate items.) fn (A) (1) Temporary total disability benefits from to at a compensation rate of per week. fn (2) Temporary total disability benefits, under section 440.15 (2)(b), Florida Statutes, from to at a compensation rate of $ per week. fn (B) Temporary partial disability benefits from to at a compensation rate of $ per week. fn (C) Impairment income benefits due under section 440.15 (3)(a), Florida Statutes, from to at a compensation rate of $ per week. fn (D) Supplemental benefits payable under section 440.15(3)(b), Florida Statutes, from to . These benefits are based on the following: fn (1) An impairment rating of 20% or more as determined under section 440.15(3)(a)2, Florida Statutes; fn (2) The fact that the injured employee has not returned to work, or has returned to work earning less than 80% of his or her average weekly wage; and fn (3) The injured employee has, in good faith, attempted to obtain employment commensurate with his or her ability to work. fn (E) Permanent total disability benefits under section 440.15(1), Florida Statutes, from to the present and continuing at a rate of $ per week. These benefits are in default and are presently ripe, due, and owing. fn (F) Death benefits payable under section 440.16, Florida Statutes. fn (G) Correction of AWW and resulting compensation rate. Basis: fn (H) Medical expenses incurred for treatment of the employee's injury as provided under section 440.13(2), Florida Statutes. The employee has specifically requested the payment of the charges, but the (employer) (E/C) (E/SA) (has) (have) failed, refused, or neglected to do so within a reasonable time. The following medical charges have not been paid (for numerous unpaid charges, a schedule in the following format may be attached): fn Name of Provider Number and Street fn City, State, and Zip Code fn Date of treatment Amount due fn Date of treatment Amount due fn Date of treatment Amount due fn Name of Provider Number and Street fn City, State, and Zip Code fn Date of treatment Amount due fn Date of treatment Amount due fn Date of treatment Amount due fn (I) Remedial or palliative care under the supervision of doctor(s): fn The employee has previously specifically requested the treatment, but the (employer) (E/C) (E/SA) (has) (have) failed, refused, or neglected to provide the treatment within a reasonable time. fn (1) The injured employee seeks fn (Type or nature of medical treatment sought). fn (2) The treatment is needed because fn (Justification for such medical treatment). fn (J) Medically necessary (professional) (nonprofessional) attendant care (performed) (to be performed) at the direction of a physician. The employee has previously specifically requested the attendant care, but the (employer) (E/C) (E/SA) (has) (have) failed, refused, or neglected to provide the care within a reasonable time. The injured employee seeks (describe type or nature of medically necessary attendant care sought). fn (Justification for such attendant care). fn (K) Transportation and/or mileage costs $ . fn (L) Rehabilitative temporary total compensation under section 440.491 (6)(b), Florida Statutes, from to at a rate of $ per week. In support thereof, the injured employee further states as follows: fn (1) The employee has reached MMI. fn (2) As authorized under section 440.491 (6)(a), Florida Statutes, the division has approved the injured employee for training and education to obtain suitable gainful employment and is receiving such training and education. fn (3) (Optional) In addition to the temporary total compensation referenced above, the injured employee also required temporary residence at or near the facility or institution(s) providing training and education which is located more than 50 miles away from the employee's customary residence. fn Attorney fees and costs under section 440.34 (3)(a)-(d), Florida Statutes. The statutory basis for the fee is: fn (N) Statutory penalties and interest: fn (1) Statutory penalty on past-due indemnity benefits. $ fn (2) Statutory interest on all past-due benefits. $ fn SECTION H: TOTAL DENIAL OF COMPENSABILITY OR OTHER ISSUE NOT REFERENCED ABOVE. fn 1. The employer/carrier/servicing agent has denied the compensability of the claim. fn 2. Give a specific explanation of any other issues the judge should consider in connection with the benefits claimed in this petition that were not referenced above. fn SECTION I: CERTIFICATE OF PETITIONER OR PETITIONER'S ATTORNEY (SECTION 440.192 (4), FLORIDA STATUTES) AND PETITIONER'S ATTESTATION (SECTION 440.105 (7), FLORIDA STATUTES). fn (print or type name of petitioner) fn (print or type name of petitioner's attorney) that a good-faith effort was made to resolve the dispute and that (he) (she) was unable to resolve the dispute with the employer/carrier/servicing agent. In accordance with section 440.192(1), Florida Statutes, a copy of this petition for benefits has been served by certified mail on the injured worker's employer and the employer's carrier, and the original and one copy on the Division of Workers' Compensation in Tallahassee on , 19 . The petitioner further attests that (he) (she) has reviewed, understands, and acknowledges the following notice: Any person who, knowingly and with intent to injure, defraud, or deceive fn any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information is guilty of a felony of the third degree. fn Signature of Petitioner fn Signature of Attorney for Petitioner ..... (address) ..... ..... (telephone number) ..... Florida Bar No. ......... fn THE ORIGINAL AND ONE COPY OF THIS PETITION MUST BE FILED WITH: fn Division of Workers' Compensation 2728 Centerview Dr., Suite 220, Forrest Building Tallahassee, FL 32399-0685 fn FORM 4.9085. NOTICE OF MEDIATION CONFERENCE AND ORDER fn [For caption and style of pleadings see Form 4.901. fn NOTICE OF MEDIATION CONFERENCE AND ORDER fn In accordance with section 440.25 (1), Florida Statutes, 1994, and Florida Rules of Workers' Compensation Procedure 4.300-4.380, a mediation conference will be held before , Mediator, at ...... (location of hearing) ..... in the above case on: fn 1. THE FOLLOWING PEOPLE MUST ATTEND THE MEDIATION CONFERENCE: fn A. petitioner; fn B. claims representative of the carrier/servicing agent, who must have full authority to settle the issues for which a petition was filed; fn C. employer, if uninsured; fn D. insured or self-insured employer, if the carrier/servicing agent does not have full authority to settle the issues for which the petition was filed; and fn E. attorneys for the parties. fn 2. The appearance of an attorney for a party does not dispense with the required attendance of the parties themselves. fn 3. No party may appear at the mediation conference by telephone unless such appearance is approved in advance by the mediator. fn 4. A party's failure to attend the mediation conference without good cause shown or appearance without full authority to resolve the issues may subject the party to sanctions such as the judge of compensation claims shall deem appropriate and may include certification for contempt, dismissal of the petition, striking of defenses, and imposition of costs and attorney fees. fn 5. If the issues in dispute are not resolved within 10 days of the commencement of the mediation conference, the mediator will so notify the judge of compensation claims, and a fn pretrial hearing will be scheduled, with at least 7 days advance notice of the date, time, and place of the pretrial being mailed to the parties. fn DONE AND ORDERED in Chambers, fn Judge of Compensation Claims fn I CERTIFY that the foregoing Notice of Mediation Conference and Order was served by mail or by hand delivery on the parties, if unrepresented, and counsel at the address written above on , 19 . fn Assistant to the Judge of Compensation Claims fn FORM 4.909. NOTICE OF FINAL HEARING AND PRETRIAL CONFERENCE 440.25(3)(b)2 fn (4)(a) fn fn fn 440.253 fn 4 fn 4.080(a) fn 4.045 fn 4.100 fn 4.085 fn trial (final hearing) and a fn and a trial (final hearing) fn If the total benefits claimed in the petition are $5,000 or less, the claim is subject to the expedited dispute resolution process of section 440.25 (4)(j), Florida Statutes. To receive expedited resolution, either party must submit an application for expedited hearing within 15 days of the date of this notice. Expedited dispute resolution is available for claims over $5,000 if all parties submit a joint application within 15 days of the date of this notice. fn FINAL fn PRETRIAL fn PRETRIAL fn FINAL fn Please note the following important instructions. Notice of trial (final hearing) and pretrial proceedings. Pretrial questionnaire and procedure for waiver of pretrial hearing. conference ( fn ) fn conference fn hearing fn conference ( fn ) fn Telephone pretrial hearings. d. fn Pretrial hearing. fn The parties must file composites of the medical reports of all authorized physicians at the pretrial hearing or 30 days before the final hearing. All witnesses must be identified at the pretrial hearing or 30 days before the final hearing. fn d fn e. fn Witnesses, Documentary Evidence, and Sanctions for Noncompliance. conference fn hearing fn conference fn hearing fn e fn f fn Final Hearing, Witnesses, and Subpoenas. f fn g fn Subpoenaed Witnesses — Failure to Appear, Sanctions. 440.33 FORM 4.9091. APPLICATION FOR EXPEDITED HEARING fn [For caption and style of pleadings, see form 4.901.] fn APPLICATION FOR EXPEDITED HEARING PURSUANT TO SECTION 440.25 (4)(j), FLORIDA STATUTES fn The (claimant) (employer/carrier/servicing agent) (applies) (apply) for an expedited hearing pursuant to section 440.25 (4)(j), Florida Statutes, and show(s) the court as follows: fn 1. A petition for benefits is properly pending before this court, having been filed on . A copy is attached and made a part of this application. fn 2. This cause previously has been the subject of a mediation conference, having been mediated by the on , more than 10 days before the filing of this application. fn 3. The issues in controversy have a value of $5,000 or less, excluding costs or attorney fees, and are composed of the following elements: fn A. Past medical charges in issue: fn B. Compensation in issue: fn C. Other (excluding costs and attorney fees): fn 4. The issues presented in this cause are proper for expedited hearing under section 440.25(4)(j), Florida Statutes. fn 5. The opposing party (has) (has not) been contacted and (does) (does not) agree to an expedited hearing. fn 6. If the amount in controversy exceeds $5,000 and the parties agree to expedited dispute resolution under section 440.25 (4)(j), Florida Statutes, both parties, or their counsel, must sign this application. fn Wherefore, (the claimant) (the employer/carrier/servicing agent) (both parties) (applies) (apply) for an expedited hearing in this cause. fn Attorney for the claimant Attorney for the E/C/SA fn I HEREBY CERTIFY that the original of this application was filed with the Office of the Judge of Compensation Claims in , County, Florida, by regular mail on , 19 , and that copies were mailed to the parties and their attorneys. fn Attorney for Applicant fn FORM 4.9092. NOTICE OF EXPEDITED HEARING AND ORDER fn For caption and style of pleadings, see Form 4.901. NOTICE OF EXPEDITED HEARING AND ORDER fn TO THE PARTIES, IF UNREPRESENTED, AND COUNSEL ADDRESSED: fn As authorized under section 440.25 (4)(j), Florida Statutes, and Florida Rule of Workers' Compensation Procedure 4.105, an expedited hearing will be held in this matter. fn The final hearing will be held in this claim at _________________, County, Florida. fn Please note the following important instructions: fn a. fn Notice of final hearing. fn Pursuant to the foregoing notice, a final hearing will be held in this matter. fn b. fn Pretrial outline. fn Pursuant to the foregoing notice, a pretrial outline shall be filed with the judge and a copy served on the opposing party. There shall be attached to the pretrial outline a composite that shall include the following: fn 1. fn Statement of the facts. fn The statement shall include references to the specific pages in the deposition testimony of witnesses as well as a suggestion of the expected testimony of those witnesses who will be called to testify at the hearing. fn 2. fn Memorandum of law. fn The memorandum shall include relevant case citations as well as copies of the cases cited. fn 3. fn Attachments. fn A complete composite of the records of the medical advisor appointed by the judge or the division, any IME physicians, and any other authorized providers shall be attached. There shall also be attached any depositions or other documentary items on which a party will rely to establish the case. The pages of the composite shall be numbered and the composite shall be preceded by an abstract referencing and synthesizing those portions of the records on which the filing party relies. No additional records, depositions, or documentary evidence will be admitted at the time of the hearing. fn c. fn Final hearing, witnesses, and subpoenas. fn At the final hearing, the parties must arrange to have all witnesses present or available to testify at the time and place noticed above. The final hearing will not exceed 30 minutes in length. The employer/carrier may be represented by an adjuster or other qualified representative. Subpoenas will be issued on request of the parties or their counsel. fn d. fn Subpoenaed witnesses — failure to appear, sanctions. fn If any party or legally subpoenaed witness fails to appear at the time and place set for this hearing, sanctions under rule 4.150 may be imposed or punitive actions authorized under sections 440.32 and 440.33, Florida Statutes, may be initiated. fn e. fn All previously scheduled final hearings and pretrial hearings are canceled. fn DONE AND ORDERED in Chambers, fn Judge of Compensation Claims fn THIS IS TO CERTIFY that the above order was entered in the office of the judge of compensation claims and a copy was served by U.S. Mail on each party and counsel at the addresses listed above on , 19 . fn Assistant to the Judge of Compensation Claims fn THIS IS THE ONLY NOTICE OF EXPEDITED HEARING YOU WILL RECEIVE. fn FORM 4.910. UNIFORM PRETRIAL STIPULATION AND PRETRIAL COMPLIANCE QUESTIONNAIRE Form for Pretrial Stipulation and Pretrial Compliance Questionnaire. 100 fn 045 fn (c) fn (c) fn order fn stipulation fn If there is a dispute as to the concurrent earnings, the claimant shall attach copies of all relevant records and submit a wage statement within 5 working days from the date of this stipulation. fn medical fn 440.13(medicals) fn NOTE: If the amount is to be determined at a hearing, under rule 4.144 the verified petition for fees must be filed 30 days before the hearing and the reply must be filed 20 days before the hearing. fn and medical composites fn and filed with the judge fn Servicing Agent: fn IV. ATTORNEYS' CERTIFICATE AND MOTION fn We certify that we have personally discussed the pretrial stipulations and the issues raised by the petition and have been unable to resolve the issues. fn Pursuant to section 440.29 (4), Florida Statutes, we, ......... (names) ..........., move into evidence all medical reports of authorized physicians exchanged to the time of the pretrial hearing or served on opposing counsel at least 30 days before the final hearing. fn (bar number) fn (bar number) fn hand fn (b)(2) fn (c), fn , or delivered by facsimile machine fn V. PRETRIAL fn The above pretrial stipulation and pretrial compliance questionnaire is hereby approved and accepted. fn 1. If done by mail, it is the responsibility of the claimant's counsel to see that a single pretrial questionnaire is completed and executed by all counsel and filed with the judge before the time noticed for the pretrial hearing; otherwise, personal appearance by all counsel is mandatory. Attendance is mandatory in all cases if the claimant is unrepresented. fn 2. All depositions that are to be considered by the judge and received into evidence must be filed fn days before the final hearing or fn at the time of the final hearing, fn unless waived by the judge. fn 3. Upon the motion of one or more parties, all medical reports of authorized physicians exchanged at the time of the pretrial hearing or served on on opposing counsel at least 30 days before the final hearing and filed with the judge accordingly are admitted into evidence. All such medical composites shall be tabulated and indexed. The parties are urged to provide the Judge with a single composite. fn 4. The above stipulations of the parties are accepted and approved by the undersigned. fn 5. The final hearing is hereby scheduled as noted above. fn this _______ day of ______________, 19 fn on .... (date) .... fn or fn , or delivered by facsimile machine fn Form for Supplemental Stipulations and Final Witness List. (bar number) fn (bar number) fn hand fn (b)(2) fn (c), fn , fn or fn , or delivered by facsimile machine fn this _____ day of _______, 19__ fn on .....(date)....... fn or fn , or delivered by facsimile machine fn FORM 4.9105 CERTIFICATE OF NOTARY PUBLIC fn Certificate of Notary Public fn The undersigned hereby certifies that: fn 1. I am a notary public or officer authorized to administer oaths in this state. fn 2. My commission number, expiration date, and seal are given and affixed below (type or stamp requested information). fn 3. On ....... (date) ......, the witness, ........(name of witness)......., who (is personally known to me) (produced the following identification: did take an oath under penalty of perjury for the purpose of giving sworn testimony at the deposition or hearing in this cause. fn 4. This certificate is being provided in compliance with Florida Rule of Workers' Compensation Procedure 4.055(d)(3), Discovery, or 4.075(f)(3), Prosecution of Claim and Petition for Benefits before Judge. fn Dated at......(city)....,....County,......(state)....,on.... (date)......... fn Signature of Notary Public fn Print or type name fn FORM 4.911 ORDERS APPROVING SETTLEMENT OF PROSPECTIVE BENEFITS fn (a) Settlements Pursuant to Section 440.20(12)(a) and (c), Florida Statutes, for Accidents Occurring After August 1, 1979, and Before October 1, 1989. fn [For caption and style of pleadings see form 4.901] fn ORDER FOR RELEASE FROM LIABILITY FOR FUTURE PAYMENTS OF COMPENSATION, REHABILITATION EXPENSES, OR DEATH BENEFITS BUT EXCLUDING MEDICAL EXPENSES fn The joint petition and stipulation for settlement pursuant to section 440.20(12)(a) and (e). Florida Statutes, and Florida Rule of Workers' Compensation Procedure 4.131, having come before the undersigned on due notice to the parties and their counsel; and having reviewed the joint petition and stipulation for settlement, the division file, and the evidence in this cause; having received in evidence the sworn proof of the employee; and having heard the argument of counsel; fn I FIND; fn (1) All requirements of section 440.20(12)(a) and (e), Florida Statutes, and rule 4.131 have been complied with. fn (2) The Employer has had adequate notice of these proceedings. fn (3) The employee [or claimant] fully understands the terms, conditions, consideration for, and consequences of the proposed settlement. fn (4) The proposed settlement is in the best interests of all parties. fn (5) The proposed settlement will further the rehabilitation of the employee [or claimant] and will otherwise benefit the employee [or claimant] to a greater extent than the payment of benefits periodically under the provisions of chapter 440, Florida Statutes. fn (6) The employee has reached maximum medical improvement more than 3 months prior to the consideration of this joint petition and stipulation for settlement. [Alternative: The employee died as a consequence of the industrial accident.] fn (7) The payment of attorney fees as set forth in the joint petition and stipulation for settlement is supported by the evidence and in compliance with the requirements of chapter 440, Florida Statutes. fn IT IS ORDERED AND ADJUDGED: fn (A) The joint petition and stipulation for settlement is approved and the parties are ordered to comply with the provisions thereof. fn (B) Upon payment of the consideration set forth in the joint petition and stipulation for settlement the liability of the employer and its carrier (or servicing agent) for future payments of compensation, rehabilitation expense, or death benefits because of the above captioned industrial accident and injury shall be fully and forever discharged and released. fn (C) The responsibility of the employer and its carrier (or servicing agent) for future medical expenses remains as it now is for the time and in the manner provided by law. fn (D) This order shall not be subject to modification or review under section 440.28, Florida Statutes. fn DONE AND ORDERED in Chambers, fn Judge of Compensation Claims fn THIS IS TO CERTIFY that the above order was entered in the office of the judge of compensation claims and a copy was served by U.S. mail on each party and counsel at the addresses listed above on ____________, 19 _____. fn Assistant to the Judge of Compensation Claims fn (b) Settlements Pursuant to Section 440.20(12)(a), Florida Statutes, for Accidents Occurring On or After October 1, 1989, and Section 440.20(12)(c) for Accidents Occurring On or After October 1, 1989, but Before July 1, 1990. fn [For caption and style of pleadings see form 4.901] fn ORDER FOR RELEASE FROM LIABILITY FOR FUTURE PAYMENTS OF COMPENSATION, REHABILITATION EXPENSES, OR DEATH BENEFITS, BUT EXCLUDING MEDICAL, TRAINING, AND EDUCATION EXPENSES fn The joint petition and stipulation for settlement pursuant to section 440.20(12)(a) and (c), Florida Statutes, and Florida Rule of Workers' Compensation Procedure 4.131, having come before the undersigned on due notice to the parties and their counsel; and having reviewed the joint petition and stipulation for settlement, the division file, and the evidence in this cause; having received in evidence the sworn proof of the employee; and having heard the argument of counsel; fn I FIND: fn (1) All requirements of section 440.20(12)(a) and (c), Florida Statutes, and rule 4.131 have been complied with. fn (2) The employer has had adequate notice of these proceedings. fn (3) The employee [or claimant] fully understands the terms, conditions, consideration for, and consequences of the proposed settlement. fn (4) The proposed settlement is in the best interests of all parties. fn (5) The proposed settlement will further the rehabilitation of the employee [or claimant] and will otherwise benefit the employee [or claimant] to a greater extent than the payment of benefits periodically under the provisions of chapter 440, Florida Statutes. fn (6) The employee has reached maximum medical improvement more than 3 months prior to the consideration of this joint petition and stipulation for settlement. [Alternative: The employee died as a consequence of the industrial accident.] fn (7) The payment of attorney fees as set forth in the joint petition and stipulation for settlement is supported by the evidence and in compliance with the requirements of chapter 440, Florida Statutes. fn IT IS ORDERED AND ADJUDGED: fn (A) The joint petition and stipulation for settlement is approved and the parties are ordered to comply with the provisions thereof. fn (B) Upon payment of the consideration set forth in the joint petition and stipulation for settlement the liability of the employer and its carrier (or servicing agent) for future benefits of compensation, or death benefits because of the above captioned industrial accident and injury shall be fully and forever discharged and released, fn (C) The responsibility of the employer and its carrier (or servicing agent) for future medical expenses, training, and education remains as it now is for the time and in the manner provided by law, fn (D) This order shall not be subject to modification or review under section 440.28, Florida Statutes, fn DONE AND ORDERED in Chambers, fn Judge of Compensation Claims fn THIS IS TO CERTIFY that the above order was entered in the office of the judge of compensation claims and a copy was served by U.S. Mail on each party and counsel at the addresses listed above on _______________, 19__. fn Assistant to the Judge of Compensation Claims fn (c) Settlements Pursuant to Section 440.20(12)(b), Florida Statutes, Before October 1, 1989. fn [For caption and style of pleadings see form 4.901] fn ORDER FOR RELEASE FROM LIABILITY FOR ALL WORKERS' COMPENSATION BENEFITS PURSUANT TO SECTION 440.20(12)(b), FLORIDA STATUTES fn The joint petition and stipulation for settlement pursuant to section 440.20(12)(b), Florida Statutes, and Florida Rule of Workers' Compensation Procedure 4.131, having come before the undersigned on due notice to the parties and their counsel; and having reviewed the joint petition and stipulation for settlement, the division file, and the evidence in this cause; having received in evidence the sworn proof of the employee; and having heard the argument of counsel; fn I FIND: fn (1) All requirements of section 440.20(12)(b), Florida Statutes, and rule 4.131 have complied with. fn (2) The employer has had adequate notice of these proceedings. fn (3) The employee fully understands the terms, conditions, consideration for, and consequences of the proposed settlement. fn (4) The proposed settlement is in the best interests of all parties. fn (5) The proposed settlement will further the rehabilitation of the employee and will otherwise benefit the employee to a greater extent than the payment of benefits periodically under the provisions of chapter 440, Florida Statutes. fn (6) The payment of attorney fees as set forth in the joint petition and stipulation for settlement is supported by the evidence and in compliance with the requirements of chapter 440, Florida Statutes. fn (7) There is a bona fide dispute and controversy as to the liability of the employer and its carrier (or servicing agent) for the payment of workers' compensation benefits as a result of the above-styled alleged industrial accident and injury. The employer and its carrier have voluntarily paid or provided no benefits and have timely controverted the claim for benefits. fn IT IS ORDERED AND ADJUDGED: fn (A) The joint petition and stipulation for settlement is approved and the parties are ordered to comply with the provisions thereof. fn (B) Upon payment of the consideration set forth in the joint petition and stipulation for settlement, the liability of the employer and its carrier (or servicing agent) for payment or provision of benefits of any class (including medical care) because of the above-captioned industrial accident and injury shall be fully and forever discharged and released. fn (C) This order shall not be subject to modification or review under section 440.28, Florida Statutes. fn (D) The employee having agreed to pay the employee's attorney a reasonable attorney fee for services, and finding that the fee is reasonable and in accordance with law, the fee as agreed to is approved. The employer and its carrier (or servicing agent) shall pay no part of the attorney fee. fn DONE AND ORDERED in Chambers, fn _______________________________ fn Judge of Compensation Claims fn THIS IS TO CERTIFY that the above order was entered in the office of the judge of compensation claims and a copy was served by U.S. Mail on each party and counsel at the addresses listed above on __________, 19__. fn -------------------------------------------------- fn Assistant to the Judge of Compensation Claims fn (d) Settlements Pursuant to Section 440.20(10), Florida Statutes (1978). fn [For caption and style of pleadings see form 4.901] fn ORDER FOR RELEASE FROM LIABILITY FOR PAYMENTS OF WORKERS' COMPENSATION PURSUANT TO SECTION 440.20 (10), FLORIDA STATUTES (1978) (PRE-AUGUST 1, 1979, DATE OF ACCIDENT) fn The joint petition and stipulation for settlement pursuant to section 440.20 (10), Florida Statutes (1978), and Florida Rule of Workers' Compensation Procedure 4.131, having come before the undersigned on due notice to the parties and their counsel; and having reviewed the joint petition and stipulation for settlement, the division file, and the evidence in this cause; having received in evidence the sworn proof of the employee; and having heard the argument of counsel; fn I FIND: fn (1) All requirements of section 440.20 (10), Florida Statutes (1978), and rule 4.131 have been complied with. fn (2) The employer has had adequate notice of these proceedings. fn (3) The employee [or claimant] fully understands the terms, conditions, consideration for, and consequences of the proposed settlement. fn (4) The proposed settlement is in the best interests of all parties. fn (5) The proposed settlement will further the rehabilitation of the employee [or claimant] and will otherwise benefit the employee [or claimant] to a greater extent than the payment of benefits periodically under the provisions of chapter 440, Florida Statutes. fn (6) The payment of an attorney fee as set forth in the joint petition and stipulation for settlement is supported by the evidence and in compliance with the requirements of chapter 440, Florida Statutes. fn IT IS ORDERED AND ADJUDGED: fn (A) The joint petition and stipulation for settlement is approved and the parties are ordered to comply with the provisions thereof. fn (B) Upon payment of the consideration set forth in the joint petition and stipulation for settlement liability of the employer and its carrier (or servicing agent) for any payments of workers' compensation benefits because of the above-captioned industrial accident and injury shall be fully and forever discharged and released. fn (C) This order shall not be subject to modification or revised under section 440.28, Florida Statutes. fn DONE AND ORDERED in Chambers, fn _______________________________ fn Judge of Compensation Claims fn THIS IS TO CERTIFY that the above order was entered in the office of the judge of compensation and a copy was served by U.S. Mail on each party and counsel at the addresses listed above on __________, 19__. fn -------------------------------------------- fn Assistant to the Judge of Compensation Claims fn (e) Settlements Pursuant to Section 440.20(12)(c), Florida Statutes (1990), for Accidents Occurring On or After July 1, 1990. fn [For caption and style of pleadings see form 4.901] fn ORDER FOR RELEASE FROM LIABILITY FOR PAYMENTS OF WORKERS' COMPENSATION PURSUANT TO SECTION 440.20 (12)(c), FLORIDA STATUTES (1990), FOR ACCIDENTS OCCURRING ON OR AFTER JULY 1, 1990 fn The joint petition and stipulation for settlement pursuant to section 440.20(12)(c), Florida Statutes (1990) and Florida Rule of Workers' Compensation Procedure 4.131, having come before the undersigned on due notice to the parties and their counsel; and having reviewed the joint petition and stipulation for settlement, the division file, and the evidence in this cause having received in evidence the sworn proof of the employee and having heard the argument of counsel; fn I FIND: fn (1) All requirements of section 440.20(12)(c), Florida Statutes (1990), and rule 4.131 have been complied with. fn (2) The employer has had adequate notice of these proceedings. fn (3) The employee (or claimant) fully understands the terms, conditions, consideration for, and consequences of the proposed settlement. fn (4) The proposed settlement is in the best interests of all parties. fn (5) The proposed settlement will further the rehabilitation of the employee (or claimant) and will otherwise benefit the employee (or claimant) to a greater extent than the payment of benefits periodically under the provisions of chapter 440, Florida Statutes. fn (6) The employee has reached maximum medical improvement [or died as a result of the industrial accident] and has not received medical care for at least 3 months prior to the date of this order. I further find that the employee has been assigned a permanent impairment rating from 1 to 5% in accordance with chapter 440.20 (12)(c), Florida Statutes, and the applicable guidelines. fn (7) The amount of settlement has been determined according to the provisions of section 440.20(12)(c), Florida Statutes. fn (8) The payment of an attorney fee as set forth in the joint petition and stipulation for settlement is supported by the evidence and in compliance with the requirements of chapter 440, Florida Statutes. fn IT IS ORDERED AND ADJUDGED: fn (A) The joint petition and stipulation for settlement is approved and the parties are ordered to comply with the provisions thereof. fn (B) Upon payment of the consideration set forth in the joint petition and stipulation for settlement the liability of the employer and its carrier (or servicing agent) for any payments of workers' compensation benefits because of the above captioned industrial accident and injury shall be fully and forever discharged and released. fn (C) This order shall not be subject to modification or review under section 440.28, Florida Statutes. fn DONE AND ORDERED in Chambers, fn ____________________________________ fn Judge of Compensation Claims fn THIS IS TO CERTIFY that the above order was entered in the office of the judge of compensation claims and a copy was served by U.S. Mail on each party and counsel at the addresses listed above on ____________, 19__. fn -------------------------------------------- fn Assistant to the Judge of Compensation Claims fn (a) Settlements Pursuant to Sections 440.20 (11)(a) and (c), Florida Statutes. fn [For caption and style of pleadings, see Form 4.901.] fn ORDER FOR RELEASE FROM LIABILITY FOR ALL WORKERS' COMPENSATION BENEFITS PURSUANT TO SECTION 440.20 (11)(a)(1994), FLORIDA STATUTES fn The parties jointly petition for an order approving a stipulation for settlement under section 440.20 (11)(a), Florida Statutes. Following review of the contents of the stipulation and supporting evidence, including the sworn statement of the employee (petitioner/claimant) incorporated into the stipulation, the following findings are made: fn 1. All requirements of section 440.20 (11)(a), Florida Statutes, and Florida Rule of Workers' Compensation Procedure 4.143 have been complied with. fn 2. The employee (petitioner/claimant) fully understands the terms, conditions, consideration for, and consequences of the proposed settlement. fn 3. The employer/carrier/servicing agent filed a written notice of denial within 120 days after the date of the injury. fn 4. The payment of attorney fees as set forth in the joint petition and stipulation for settlement is supported by the evidence and is in compliance with the requirements of chapter 440, Florida Statutes. fn 5. The proposed settlement is not in excess of the value of benefits the employee would be entitled to receive under chapter 440, Florida Statutes. fn 6. There is a bona fide justifiable controversy as to the legal and medical compensability of the claimed injury or alleged accident. fn 7. The proposed settlement will definitely aid in the rehabilitation of the employee or otherwise is clearly in the best interests of all parties. fn IT IS ORDERED AND ADJUDGED: fn A. The joint petition and supporting stipulation for settlement are approved and the parties are ordered to comply with the provisions thereof. fn B. On payment of the consideration set forth in the joint petition and supporting stipulation for settlement, the liability of the employer and its carrier (servicing agent) for the payment or provision of any class of benefits including medical benefits payable under the Florida Workers' Compensation Law because of the alleged industrial accident and injury referenced herein is hereby fully and forever discharged and released. fn C. This order shall not be subject to modification or review under section 440.28, Florida Statutes. fn DONE AND ORDERED in Chambers, fn fn THIS IS TO CERTIFY that the above order was entered in the office of the Judge of Compensation Claims and a copy was served by U.S. Mail on each party and counsel at the addresses listed above on , 19 . fn Assistant to the Judge of Compensation Claims fn (b) Settlements Pursuant to Section 440.20 (11)(b), Florida Statutes (1994). fn [For caption and style of pleadings, see form 4.901.] fn ORDER FOR RELEASE FROM LIABILITY FOR PAYMENTS OF WORKERS' COMPENSATION PURSUANT TO SECTION 440.20 (11)(b), FLORIDA STATUTES (1994) fn The parties jointly petition for an order approving a stipulation for settlement under section 440.20 (11)(b), Florida Statutes. On review of the contents of the stipulation and evidence submitted in support thereof including the sworn statement of the employee (petitioner/claimant) incorporated into the stipulation, the following findings are made: fn 1. All requirements of section 440.20 (11)(b), Florida Statutes, and Florida Rule of Workers' Compensation Procedure 4.143 have been complied with. fn 2. The employee (petitioner/claimant) fully understands the terms, conditions, consideration for, and consequences of the proposed settlement. fn 3. The employer has adequate notice of these proceedings. fn 4. The injured employee has attained maximum medical improvement. fn 5. The payment of attorney fees as set forth in the joint petition and stipulation for settlement is supported by the evidence and is in compliance with the requirements of chapter 440, Florida Statutes. fn 6. The proposed settlement is not in excess of the value of benefits the employee would be entitled to receive under chapter 440, Florida Statutes. fn 7. The proposed settlement definitely will aid in the rehabilitation of the injured employee or otherwise is clearly in the best interests of all parties. fn IT IS ORDERED AND ADJUDGED: fn A. The stipulation in support of the joint petition for settlement is approved and the parties are ordered to comply with the provisions thereof. fn B. On payment of the consideration set forth in the joint petition and supporting stipulation for settlement, the liability of the employer and its carrier (servicing agent) for the payment or provision of any class of benefits including medical benefits payable under the Florida Workers' Compensation Law because of the alleged industrial accident and injury referenced herein is hereby fully and forever discharged and released. fn C. This order shall not be subject to modification or review under section 440.28, Florida Statutes. fn DONE AND ORDERED in Chambers, fn Judge of Compensation Claims fn THIS IS TO CERTIFY that the above order was entered in the office of the Judge of Compensation Claims and a copy was served by U.S. Mail on each party and counsel at the addresses listed above on , 19 . fn Assistant to the Judge of Compensation Claims fn (c) Settlements Pursuant to Section 440.20 (11)(b), Florida Statutes (1994), in which Right to Future Medical Benefits Is Left Open. fn [For caption and style of pleadings, see form 4.901.] fn ORDER FOR RELEASE FROM LIABILITY FOR PAYMENTS OF WORKERS' COMPENSATION PURSUANT TO SECTION 440.20 (11)(b), FLORIDA STATUTES (1994) fn RIGHT TO FUTURE MEDICAL BENEFITS LEFT OPEN fn The parties jointly petition for an order approving a stipulation or settlement under section 440.20 (11)(b), Florida Statutes. On review of the contents of the stipulation and evidence submitted in support thereof including the sworn statement of the employee (petitioner/claimant) incorporated into the stipulation, the following findings are made: fn 1. All requirements of section 440.20 (11)(b), Florida Statutes, and Florida Rule of Workers' Compensation Procedure 4.143 have been complied with. fn 2. The employee (petitioner/claimant) fully understands the terms, conditions, consideration for, and consequences of the proposed settlement. fn 3. The employer has adequate notice of these proceedings. fn 4. The injured employee has attained maximum medical improvement. fn 5. The payment of attorney fees as set forth in the joint petition and stipulation for settlement is supported by the evidence and is in compliance with the requirements of chapter 440, Florida Statutes. fn 6. The proposed settlement is not in excess of the value of benefits the employee would be entitled to receive under chapter 440, Florida Statutes. fn 7. The proposed settlement definitely will aid in the rehabilitation of the injured employee or otherwise is clearly in the best interests of all parties. fn IT IS ORDERED AND ADJUDGED: fn A. fn Approval. fn The stipulation in support of the joint petition for settlement is approved, and the parties are ordered to comply with the provisions thereof. fn B. fn Release. fn [On payment of the consideration set forth in the joint petition and supporting stipulation for settlement, the liability of the employer and its carrier (servicing agent) for the payment or provision of any class of benefits except medical benefits payable under the Florida Workers' Compensation Law because of the alleged industrial accident and injury referenced herein is hereby fully and forever discharged and released. fn (Complete only one of the following two paragraphs; strike through the one that is not applicable.) fn C. fn Limited Liability for Medical Benefits. fn The employer and its carrier (servicing agent) shall remain responsible for medical benefits due the employee on account of the industrial injury for (months) (years) from the date of this order, after which the liability of the employer/(carrier)/(servicing/agent) for any further medical benefits shall be fully and forever discharged and released without further order. fn OR fn C. fn Continuing Liability for Medical Benefits. fn The responsibility of the employer and its carrier (or servicing agent) for future medical expenses remains as it now is for the time and in the manner provided by law. fn D. fn Modification. fn This order shall not be subject to modification or review under section 440.28, Florida Statutes. fn DONE AND ORDERED in Chambers, fn Judge of Compensation Claims fn THIS IS TO CERTIFY that the above order was entered in the office of the Judge of Compensation Claims and a copy was served by U.S. Mail on each party and counsel at the addresses listed above on , 19 . fn Assistant to the Judge of Compensation Claims fn (d) Settlements Pursuant to Sections 440.20 (11)(b) and (c) (1994), Florida Statutes, in which Right to Compensation Benefits Has Been Settled Previously. fn [For caption and style of pleadings, see form 4.901] fn ORDER FOR RELEASE FROM LIABILITY FOR MEDICAL BENEFITS PAYABLE UNDER SECTION 440.13, FLORIDA STATUTES, AS AUTHORIZED BY SECTIONS 440.20 (11)(b) and (c) (1994), FLORIDA STATUTES fn The parties jointly petition for an order approving a stipulation for settlement under sections 440.20 (11)(b) and (c) (1994), Florida Statutes, which permit settlement of all claims not previously settled regardless of the date of accident. On (date), an order was entered in this cause releasing the employer/carrier/servicing agent from any further liability for indemnity benefits payable on account of disability, however, as required by the law in effect at the time, the employer/carrier/servicing agent continued to be liable to provide medical benefits to the injured employee. For promised additional consideration as set forth in the stipulation in support of the joint petition the parties have now agreed to settle the employee's (petitioner's/claimant's) right to receive any further medical benefits under the Florida Workers' Compensation Law. On review of the contents of the stipulation and evidence submitted in support thereof including the sworn statement of the employee (petitioner/claimant) incorporated into the stipulation, the following findings are made: fn 1. All requirements of section 440.20 (11)(b), Florida Statutes, and Florida Rule of Workers' Compensation Procedure 4.143 have been complied with. fn 2. The employee (petitioner/claimant) fully understands the terms, conditions, consideration for, and consequences of the proposed settlement of future medical benefits. fn 3. The employer has adequate notice of these proceedings. fn 4. The injured employee has attained maximum medical improvement. fn 5. The additional consideration paid by the employer/carrier/servicing agent is adequate and reasonable to compensate the injured employee for releasing his or her right to future medical benefits and definitely will aid in the rehabilitation of the injured employee or otherwise is clearly in the best interests of all parties. fn 6. The proposed settlement is not in excess of the value of benefits the employee would be entitled to receive under chapter 440, Florida Statutes. fn 7. The payment of attorney fees as set forth in the joint petition stipulation for settlement is supported by the evidence and is in compliance with the requirements of chapter 440, Florida Statutes. fn IT IS ORDERED AND ADJUDGED: fn A. The stipulation in support of the joint petition for settlement is approved, and the parties are ordered to comply with the provisions thereof. fn B. On payment of the additional consideration set forth in the joint petition and supporting stipulation for settlement, the liability of the employer and its carrier (servicing agent) for the payment or provision of medical benefits under section 440.13, Florida Statutes, because fn of the industrial accident and injury referenced herein is hereby fully and forever discharged and released. fn C. This order shall not be subject to modification or review under section 440.28, Florida Statutes. fn DONE AND ORDERED in Chambers, fn Judge of Compensation Claims fn THIS IS TO CERTIFY that the above order was entered in the office of the Judge of Compensation Claims and a copy was served by U.S. Mail on each party and counsel at the addresses listed above on , 19 . fn Assistant to the Judge of Compensation Claims fn FORM 4.912. NOTICE OF ESTIMATED COST OF PREPARATION OF RECORD ON APPEAL f fn e fn f fn e fn Notice of Estimated Costs. The judge shall also notify the division of the estimated record costs if the appellant files a verified petition to be relieved of costs and a sworn financial affidavit in substantially the same form as form 4.9125. fn Deposit of Estimated Costs. Failure to Deposit Costs. State Agencies: Waiver of Costs. rule 4.180 (g) and fn 440.255 fn and rule 4.180 (f)(2) fn together fn s fn g fn f fn Authority. also fn such fn and a copy of the designation of the record on appeal. The verified petition to be relieved of costs shall contain a sworn financial affidavit as described in subdivision (D) below in a form substantially the same as form 4.9125. fn Time. A verified petition filed before the date of service of the notice of estimated costs shall be deemed not timely. fn Verified Petition: Contents. to be relieved of costs shall include the appellant sworn financial statement listing his or her income, expenses, assets, and liabilities. fn shall contain a request by the appellant to be relieved of costs due to insolvency. fn could fn could fn and shall state with particularity the specific legal and factual grounds for that opinion. fn (D) fn Sworn Financial Affidavit: Contents. fn With the verified petition to be relieved of costs, the appellant shall file a sworn financial affidavit listing income and assets, including marital income and assets, and expenses and liabilities. The sworn financial affidavit shall be substantially the same as form 4.9125. fn D fn E fn Verified Petition and Sworn Financial Affidavit: fn Service. to be relieved of costs, including the sworn financial affidavit, on all interested parties, including fn on fn and fn , and all parties. fn E fn F fn Hearing on Petition to Be Relieved of Costs. 12 fn 20 fn filed fn served, fn F fn G fn Extension of Appeal Deadlines: Petition Granted. G fn H fn Extension of Appeal Deadlines: Petition Denied. H fn I fn Payment of Cost for Preparation of Record by Administration Trust Fund. I fn J fn Reimbursement of Administration Trust Fund If Appeal Is Successful. division, fn FORM 4.9125. FINANCIAL AFFIDAVIT IN SUPPORT OF VERIFIED PETITION FOR RELIEF FROM COSTS fn STATE OF FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY OFFICE OF THE JUDGE OF COMPENSATION CLAIMS DISTRICT ..... (district number) ..... fn STATE OF FLORIDA, ATTORNEY FOR STATE: DEPARTMENT OF LABOR ..... (Name) ..... AND EMPLOYMENT SECURITY, ..... (Address) ..... DIVISION OF WORKERS' COMPENSATION fn CLAIMANT: ATTORNEY FOR CLAIMANT ..... (Name) ..... ..... (Name) ..... ..... (Address) ..... ..... (Address) ..... fn EMPLOYER: ATTORNEY FOR EMPLOYER/ CARRIER/SERVICING AGENT: ..... (Name) ..... ..... (Name) ..... ..... (Address) ..... ..... (Address) ..... fn CARRIER/SERVICING AGENT: ..... (Name) ..... CLAIM NUMBER: ..... (Address) ..... DATE OF ACCIDENT: fn FINANCIAL AFFIDAVIT fn STATE OF FLORIDA COUNTY OF .......... fn BEFORE ME, this day personally appeared , who being duly sworn, deposes and says that the following information is true and correct according to his/her best knowledge and belief: fn ITEM 1: EMPLOYMENT AND MONTHLY INCOME fn AVERAGE GROSS MONTHLY INCOME FROM EMPLOYMENT fn Bonuses, commissions, allowances, overtime, tips, and similar payments fn Business income from sources such as self-employment, partnership, close corporations, and/or independent contracts (gross receipts minus ordinary and necessary expenses required to produce income) fn Disability benefits fn Workers' compensation fn Unemployment compensation fn Pension, retirement, annuity payments fn Social Security benefits fn Spousal support received from previous marriage fn Interest and dividends fn Rental income (gross receipts minus ordinary and necessary expenses required to produce income) fn Income from royalties, trusts, or estates fn Reimbursed expenses and in kind payments to the extent that they reduce personal living expenses fn Gains derived from dealing in property (not including nonrecurring gains) fn Itemize any other income of a recurring nature fn TOTAL MONTHLY INCOME fn LESS DEDUCTIONS: fn Federal, state, and local income taxes (corrected for filing status and actual number of withholding allowances) fn FICA or self-employment tax (annualized) fn Mandatory union dues fn Mandatory retirement fn Health insurance payments fn Court-ordered support payments for children actually paid fn TOTAL DEDUCTIONS fn TOTAL MONTHLY INCOME fn LESS TOTAL DEDUCTIONS fn NET MONTHLY INCOME fn DOES ANYONE CONTRIBUTE TO YOUR INCOME OR HELP PAY YOUR EXPENSES (SPOUSE, ROOMMATE, ETC.)? YES NO fn IF "YES" COMPLETE THE FOLLOWING: fn ame of Relationship to Total Monthly Dollar Contributor Claimant Amount of Contribution fn ITEM 2 — HOUSEHOLD: AVERAGE MONTHLY EXPENSES fn Mortgage or rent payments fn Property taxes and insurance fn Electricity fn Water, garbage, and sewer fn Telephone fn Fuel oil or natural gas fn Pest control fn Food and grocery items fn Other: fn AUTOMOBILE: fn Loan payment fn Auto tags and license fn Insurance fn Other fn INSURANCE: fn Health fn Life fn Other: fn OTHER EXPENSES NOT LISTED ABOVE: fn TOTAL HOUSEHOLD EXPENSES: fn PAYMENTS TO CREDITORS: fn TO WHOM: BALANCE DUE: MONTHLY PAYMENT fn TOTAL MONTHLY PAYMENTS TO CREDITORS: fn TOTAL MONTHLY EXPENSES: fn SUMMARY OF INCOME AND EXPENSES fn TOTAL MONTHLY NET INCOME fn MONTHLY CONTRIBUTION — OTHERS fn SUBTOTAL fn LESS TOTAL MONTHLY EXPENSES fn BALANCE (+ OR -) fn ITEM 3: ASSETS (If jointly owned, indicate your share and ownership interest of others.) fn Description fn Cash (on hand or in banks) fn Stocks/bonds/notes fn Real estate: Home fn Automobiles: fn Make Model Year Value fn Money held in escrow by your attorney on your behalf fn Other personal property: fn Contents of home fn Jewelry fn Life insurance/cash surrender value fn Other assets: fn TOTAL ASSETS: fn ITEM 4: LIABILITIES (if joint, allocate equally and indicate your share only) fn Creditor Security Balance fn TOTAL LIABILITIES: fn SUMMARY OF ASSETS AND LIABILITIES fn TOTAL ASSETS fn LESS TOTAL LIABILITIES fn NET WORTH fn AFFIANT/APPELLANT SWORN TO and SUBSCRIBED before me this day of 199 by fn (Signature of Notary Public — State of Florida) fn (Print, Type, or Stamp Commissioned Name of Notary Public) fn Personally Known OR Produced Identification fn Type of Identification Produced fn CERTIFICATE OF SERVICE fn I HEREBY CERTIFY that a true and correct copy of the above Financial Affidavit has been furnished by this day of 19 to: fn Appellant/Appellant's Attorney fn FORM 4.913 SUBPOENA (a) Subpoena for Trial or Deposition. DIVISION OF WORKERS' COMPENSATION fn (bar number) fn (b) Subpoena Duces Tectum for Trial or Deposition. DIVISION OF WORKERS' COMPENSATION fn (bar number) fn [FORM 4.914. PROOF OF CLAIM FOR SUBMISSION TO SPECIAL DISABILITY TRUST FUND fn PROOF OF CLAIM THE SPECIAL DISABILITY TRUST FUND 535 JOHN KNOX ROAD TALLAHASSEE, FLORIDA 32399 fn a. Employee's Social Security Number: fn b. Date of Accident for Which Reimbursement Is Claimed: fn c. Date of This Claim: fn d. Name of Employee: (address) (telephone number) fn e. Name of Employer: (address) (telephone number) fn f. Name of Carrier/Servicing Agent/Self Insured: (address) (telephone number) fn g. Brief summary of theory of merger, including preexisting condition claimed and explanation of how it merged with instant accident to cause payment of excess permanent compensation. State whether merger is a wage loss or a medical merger. fn 1. Preexisting fn 2. Subsequent fn 3. Merger fn 4. Excess fn 5. Employer Knowledge fn h. Date of Maximum Medical Improvement: fn i. Date of First Payment of Permanent Benefits: fn j. Permanent Impairment Rating: fn k. Amount of Permanent Benefits Paid: fn l. January 1, 1994: Temporary Compensation/Medical: fn m. Deductible Met and Date: fn PLEASE COMPLETE THE ATTACHED SCHEDULES AND FURNISH APPROPRIATE DOCUMENTATION. ONCE A COMPLETED APPLICATION IS RECEIVED, YOUR CLAIM WILL BE FILED AND PLACED IN LINE FOR REVIEW. INCOMPLETE CLAIMS WILL NOT BE PLACED IN LINE. fn I hereby certify that I have made a good-faith effort to enclose all pertinent materials requested. fn Attorney for Employer/Carrier/Servicing Agent Date ..... (address) ..... ..... (telephone number) ..... Florida Bar No. ..... (bar number) ..... fn FORM 4.915. UNIFORM SPECIAL DISABILITY TRUST FUND PRETRIAL STIPULATION, PRETRIAL COMPLIANCE QUESTIONNAIRE, AND ORDER fn STATE OF FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY OFFICE OF THE JUDGE OF COMPENSATION CLAIMS DISTRICT ....... (district number) ...... fn vs. fn SPECIAL DISABILITY TRUST FUND fn Uniform Special Disability Trust Fund Pretrial Stipulation, Pretrial Compliance Questionnaire, and Order fn As authorized under Florida Rules of Workers' Compensation Procedure 4.025 and 4.045, and as ordered by the judge of compensation claims, the parties hereby provide the following information and make the following stipulations: fn FINAL HEARING SCHEDULED: fn DATE: fn TIME: fn PLACE: fn NOTE: fn THIS IS THE ONLY NOTICE OF FINAL HEARING YOU WILL RECEIVE. fn I. STIPULATIONS fn Employer/Carrier ___________________ SDTF fn 1. JURISDICTION OF THE PARTIES AND SUBJECT MATTER fn 2. VENUE fn 3. NOTICE OF REIMBURSEMENT FILED ON fn 4. DATE OF DENIAL AND DATE OF APPLICATION FOR HEARING fn 5. PREEXISTING PERMANENT IMPAIRMENT (please specify) fn 6. THE EMPLOYER REACHED AN INFORMED CONCLUSION PRIOR TO THE INSTANT ACCIDENT THAT THE EMPLOYEE HAD A PHYSICAL IMPAIRMENT THAT WAS PERMANENT AND WAS OR WAS LIKELY TO BE A HINDRANCE OR OBSTACLE TO EMPLOYMENT fn 7. PERMANENT IMPAIRMENT AS A RESULT OF INSTANT ACCIDENT fn 8. MERGER fn 9. PAYMENT OF EXCESS fn II. CLAIMS AND DEFENSES fn 1. The E/C's reasons why their claim should be approved. (Theory of merger and cite with specificity). fn 2. Type of reimbursement(s) to which E/C claim they are entitled. (Permanent total, permanent impairment, death, etc.) List: fn A. Type of permanent benefits claimed for reimbursement. fn B. Specify whether reimbursement is being claimed on medical and temporary benefits without permanent impairment. fn C. Specify whether reimbursement is being claimed on medical and temporary benefits with permanent impairment. fn 3. The E/C's issues to be decided by this court. fn 4. The SDTF's reason(s) for denying this claim (cite with specificity). fn 5. The SDTF's issues to be decided by this court. fn THE JUDGE OF COMPENSATION CLAIMS RESERVES THE RIGHT TO IMPOSE SANCTIONS FOR FAILURE TO SPECIFICALLY ANSWER THE FORGOING IN GOOD FAITH. A REFERENCE TO ANOTHER PLEADING OR TO A GENERAL CLASS OF BENEFITS IS INSUFFICIENT. ANY ISSUE NOT SPECIFICALLY RAISED IN THIS SECTION WILL BE DEEMED WAIVED OR ABANDONED UNLESS GOOD CAUSE IS SHOWN. fn III. WITNESSES AND EVIDENCE fn 1. List witnesses to testify live, by telephone, or by deposition. Final witness lists must be filed with the judge and served on opposing parties at the time of the pretrial hearing or 30 days before the final hearing, whichever comes first. All discovery must be noticed at least 21 days before the final hearing. Depositions and stipulated medical composites must be filed 48 hours before the final hearing. fn Employer/Carrier: Depo Live Phone fn Special Disability Trust Fund: Depo Live Phone fn 2. Attach copies of all documentary evidence (including medical and rehabilitation reports and bills) to be used at the final hearing if not previously furnished to opposing party or counsel. If previously furnished, identify the documentary evidence to be introduced at the final hearing in a separate schedule attached to this compliance. Each party must indicate any documents NOT stipulated into evidence without sworn proof. fn Documentary Evidence Listed Below: fn Employer/Carrier: SDTF SDTF Disagrees Agrees fn SDTF: E/C E/C Disagrees Agrees fn 3. Estimated time for final hearing: fn IV. ATTORNEYS' CERTIFICATE fn We certify that we have personally discussed the pretrial stipulations and the issues raised by the claim and have been unable to resolve the issues. fn Attorney for E/C [Attorney for SDTF Date: Date: ..... (address) ..... ..... (address) ..... ..... (telephone number) ..... ..... (telephone number) ..... Florida Bar No. .......... Florida Bar No. .......... fn V. PRETRIAL ORDER fn 1. If done by mail, it is the responsibility of the E/C's counsel to see that a single pretrial questionnaire is completed and executed by all counsel and filed with the judge before the time noticed for the pretrial hearing; otherwise, personal appearance by all counsel is mandatory. fn 2. All depositions or stipulated medical reports that are to be admitted into evidence must be filed with the undersigned judge 48 hours before the time of the final hearing to be considered and received into evidence. fn 3. If medical reports are stipulated into evidence, it shall be the responsibility of E/C's counsel to file a tabulated and indexed medical composite. fn 4. All discovery must be noticed at least 21 days before the final hearing. fn 5. Witness lists must be filed with the judge and exchanged between the parties at the time of the pretrial hearing or 30 days before final hearing. fn 6. The above stipulations of the parties are accepted and approved by the undersigned. fn 7. The final hearing is hereby scheduled as noted above. fn DONE AND ORDERED in Chambers. fn Judge of Compensation Claims fn I certify that a copy of the foregoing stipulation was mailed or hand delivered to the above-named parties and counsel on 19 fn Assistant to the Judge of Compensation Claims fn FORM 4.916. UNIFORM PRETRIAL STIPULATION AND ORDER FOR PENALTY CASES fn STATE OF FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY OFFICE OF THE JUDGE OF COMPENSATION CLAIMS DISTRICT ....... (district number) ...... fn STATE OF FLORIDA, DEPARTMENT OF ATTORNEY FOR STATE: LABOR AND EMPLOYMENT SECURITY, ..... (name) ..... DIVISION OF WORKERS' COMPENSATION ..... (address) ..... fn CLAIMANT: ATTORNEY FOR CLAIMANT: ..... (name) ..... ..... (name) ..... ..... (address) ..... ..... (address) ..... fn EMPLOYER: ATTORNEY FOR EMPLOYER/CARRIER ..... (name) ..... ..... (name) ..... ..... (address) .....]fn ..... (address) ..... fn CARRIER/SERVICING AGENT CLAIM NUMBER: ..... (name) ..... ..... (address) ..... DATE OF ACCIDENT: fn Uniform Pretrial Stipulation and Order Penalty Case fn As authorized under Florida Rule of Workers' Compensation Procedure 4.045, or as ordered by the judge, the parties hereby provide the following information and make the following stipulations: fn I. STIPULATIONS fn 1. Date of Accident: fn E/C/SA ________________ State _______________ fn 2. Date employee first notified employer of accident: fn E/C/SA ________________ State _______________ fn 3. Transmittal of form DWC-1, Notice of Injury, by employer to carrier or by carrier/servicing agent to state (to be completed by E/C/SA): fn II. DEFENSES TO PENALTY ASSESSMENT ORDERS fn 1. State: Attach copies of all Penalty Assessment Orders. fn 2. Employer: Specify each defense to the state's allegation that you failed to timely file for DWC-1, Notice of Injury, with your insurance carrier. fn OR fn 3. Carrier/Servicing Agent: Specify each defense to the state's allegation that you failed to timely file form DWC-1, Notice of Injury, with the Department of Labor and Employment Security, Division of Workers' Compensation. fn III. WITNESSES AND EVIDENCE fn 1. List witnesses to testify live, by telephone, or by deposition. Final witness lists shall be served on opposing parties no later than 5 days before the final hearing. Depositions shall be filed 5 days before the final hearing. fn Employer/Carrier/SA Depo Live Phone fn State of Florida Depo Live Phone fn 2. Attach copies of all documentary evidence to be used at the final hearing. Each party must indicate any documents NOT stipulated into evidence. fn 3. Documentary evidence NOT stipulated into evidence: fn (a) Employer/carrier/servicing agent: fn (b) State of Florida: fn THE OFFICE OF THE JUDGE MUST BE NOTIFIED BY THE TELEPHONE OR BY SEPARATE LETTER IMMEDIATELY IF THE FINAL HEARING WILL REQUIRE MORE THAN 1 HOUR. THE JUDGE RESERVES THE RIGHT TO IMPOSE SANCTIONS FOR FAILURE TO SPECIFICALLY ANSWER THE FOREGOING IN GOOD FAITH. A REFERENCE TO ANOTHER PLEADING OR TO A GENERAL DEFENSE IS INSUFFICIENT. ANY ISSUES OR EVIDENCE NOT SPECIFICALLY RECITED IN THIS STIPULATION WILL BE DEEMED WAIVED OR ABANDONED UNLESS GOOD CAUSE IS SHOWN. fn Employer/Carrier/Servicing Agent fn fn Attorney for Employer/Carrier/Servicing Agent fn ..... (name) ..... ..... (address)..... Florida Bar No. .......... fn fn Attorney for State of Florida Division of Workers' Compensation fn ..... (name) ..... ..... (address)..... fn Florida Bar No. .......... fn To be completed by the Employer/Carrier/Servicing Agent: fn CERTIFICATE OF SERVICE fn I hereby certify that the original of the foregoing has been furnished to .....(name) ....., Department of Labor and Employment Security, Office of the General Counsel, ..... (address) ....., on 19 fn For Employer/Carrier/Servicing Agent fn To be completed by the State of Florida: fn CERTIFICATE OF SERVICE fn I hereby certify that the original and one copy of the foregoing stipulation has been furnished to the Honorable Judge of Compensation Claims, and a copy furnished to the Employer/Carrier/Servicing Agent as follows: fn For State of Florida, Department of Labor and Employment Security fn PRETRIAL ORDER fn The above pretrial stipulations are hereby approved and accepted. The State of Florida, Department of Labor and Employment Security, Division of Workers' Compensation, shall schedule and file a notice of final hearing within 30 days from the date of this order. fn Done and Ordered in Chambers. fn Judge of Compensation Claims fn I certify that a copy of the foregoing stipulation and order was mailed or hand delivered to the above-named parties and counsel of record on 19 fn Assistant to the Judge of Compensation Claims fn
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