Certificate of Good Faith Effort to Resolve Dispute - Acknowledgment of Fraud Statement - Service and Social Security Number Notice

Sep 16, 2026

Uploaded by Bintang

Certificate text for a workers’ compensation petition in Florida addressing multiple legal notices. It certifies a claimant and counsel made a good faith effort to resolve the dispute before litigation and acknowledges a fraud warning under Florida law. It documents service of the petition by certified mail to the injured worker’s employer and carrier, identifies service to opposing counsel when known, and explains voluntary SSN disclosure and substitute ID requirements. It also details confidentiality rules and limited authorized SSN disclosures, concluding with requests for benefits and signature/date fields.

LanguageEnglish

CategoryForms

FormatPDF

Pages1

AccessFree to download

Certificate notices

Good faith effort certification and fraud acknowledgment

Service of petition and petition processing

Social Security Number disclosure and confidentiality

Certificate of Good Faith Effort to Resolve Dispute, Acknowledgment of Fraud Statement, Certificate of Service, and Social Security Number Notice The Claimant and the Claimant's attorney certify that they have made a good faith effort to resolve the dispute and that the Claimant and the Claimant's attorney were unable to resolve the dispute with the employer/carrier/servicing agent. The Claimant has read and understands the following: "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 commits insurance fraud , punishable as provided ins . 817.234." By signing below , the Claimant attests that he or she has reviewed, understands, and acknowledges the foregoing notice . In accordance with Florida Statutes § 440 . 192( 1 ) , a copy of this Petition for Benefits has been served by Certified Mail on the injured worker’s employer and the employer’s carrier on . A copy of this Petition has also been served on the attorney for the employer/carrier, if known . Disclosure of the employee ’s Social Security Number ( SSN ) is voluntary. An employee or claimant who does not have or declines to provide the employee’s SSN must file a verified motion for assignment of substitute identification number along with the initial Petition for Benefits or Request for Assignment of Case Number in accordance with Fla. Admin. Code 60Q-6.105(4) . The employee’s SSN will be used to uniquely identify the employee in the Office of the Judges of Compensation Claims (OJCC) case management system , ascertain a claimant’s child support obligations before approving any lump sum settlement, and exchange information between the OJCC and the Division of Workers’Compensation . The employee’s SSN may also be used by the employer and carrier named on the Petition for Benefits or Request for Assignment of Case Number to identify the employee . Social Security Numbers are confidential and exempt from public disclosure . It is the express policy of the OJCC to prohibit the disclosure of Social Security Numbers by the OJCC or any of its employees, except the SSN will be disclosed by the OJCC for the following reasons: ( 1 ) in response to a legitimate inquiry from a state or federal agency in connection with matters within its jurisdiction; (2 ) if so ordered by a court of competent jurisdiction , pursuant to the terms of such order ; and (3 ) to a commercial entity in response to a request in accordance with §119.071(5)(a)(7 ), Florida Statutes . WHEREFORE, the Claimant requests an order directing the employer to provide the benefits as requested. U Signature of Claimant Signature of Counsel for Claimant Date Date

FAQs

What does the claimant and counsel certify about resolving the dispute?

They certify they made a good faith effort to resolve the dispute and were unable to resolve it with the employer/carrier/servicing agent.

What fraud warning does the claimant acknowledge when signing?

The claimant acknowledges that filing a statement of claim with false or misleading information with intent to defraud or deceive constitutes insurance fraud, punishable under Florida law.

How is the claimant’s Social Security Number (SSN) handled and when can it be disclosed?

SSN disclosure is voluntary; if not provided, a verified motion for substitute identification must be filed. SSNs are confidential and exempt from public disclosure, and disclosure by OJCC is limited to specified agency requests, court orders, or requests under Florida statutory procedures.

Sep 16, 2026

Uploaded by Bintang