How to Fill Out Florida Form P-5.0900 (w/Examples) + FAQs

Florida Form P-5.0900 is the Petition for Benefits (PFB), the document an injured worker, or the worker’s attorney, files with the Florida Office of the Judges of Compensation Claims to demand specific workers’ compensation benefits the employer or carrier has refused to provide. It is the gateway pleading in any disputed Florida workers’ compensation case under Chapter 440, Florida Statutes, and without it, a judge has no power to order benefits.

If the form is wrong, late, or vague, the carrier can move to dismiss it, and a dismissal can mean weeks of lost indemnity checks, unpaid medical bills, and a missed two-year statute of limitations. The OJCC reports that more than 30,000 Petitions for Benefits are filed every year in Florida, and a sizable share are dismissed on technical grounds before a judge ever hears the merits.

• 📝 How to complete every box on the current revision of Form P-5.0900 line by line
• ⚖️ How Chapter 440 and Rule 60Q-6.107 shape what you can and cannot ask for
• 💻 How to e-file through the e-JCC portal and how pro se filers can mail or hand-deliver
• 🔍 The most common mistakes that cause dismissal and how to avoid them
• 📂 Three full walk-through scenarios with named filers and exact entries

What the Form Is and Who Must File It

Form P-5.0900 is the official Petition for Benefits approved by the OJCC and described in Rule 60Q-6.107, Florida Administrative Code. It is the only pleading that triggers a Florida workers’ compensation case, and it must be filed by the injured worker, called the claimant, or by the claimant’s attorney of record. Employers, carriers, and third-party administrators do not file PFBs; they respond to them.

The form is required any time an injured worker wants a judge to order a benefit the carrier has denied, delayed, or ignored. Common examples include unpaid temporary total disability (TTD), temporary partial disability (TPD), permanent total disability (PTD), authorization of a specific doctor, surgery, MRI, mileage reimbursement, attendant care, and attorney’s fees under the Castellanos v. Next Door Co. line of cases. The carrier then has 14 days to pay, deny, or otherwise respond under Section 440.192(8), Florida Statutes.

A claimant who files without an attorney is called a pro se filer, and the OJCC publishes a pro se information packet to help. A claimant who is represented must file electronically; pro se filers may file electronically, by mail, or in person at the district office where the accident happened.

Before You Start: Documents and Information You Need

The PFB asks for very specific data, and missing any one item can stall your case. Pull every document below before you open the form, because you cannot save a partial draft on the OJCC public portal and come back to it later.

• Date of accident in MM/DD/YYYY format, taken from the First Report of Injury (DWC-1) — without it, the clerk cannot index your case.
• OJCC case number if one already exists (format: YY-XXXXXXX) — filing a new PFB on an existing case under a different number creates a duplicate file.
• Employer’s full legal name and FEIN — the trade name alone (e.g., “Bob’s Pizza”) will not match the carrier’s records.
• Carrier or servicing agent name and claim number — pulled from the most recent benefit check stub or denial letter, because the wrong carrier means the wrong respondent.
• Your Social Security number and date of birth — used by the OJCC to cross-match medical and indemnity records.
• A specific list of benefits requested with dates and dollar amounts — vague requests like “all benefits owed” are routinely dismissed.
• Medical records or doctor’s notes supporting each requested benefit, especially for surgery, MRIs, or PTD.
• Proof of a good-faith effort to resolve the dispute with the adjuster, required by Rule 60Q-6.115 — usually an email or letter to the adjuster at least a few days before filing.
• Notice of Appearance if an attorney is filing for you — the PFB is rejected if counsel has not appeared.
• A working email address for e-service of every future document in the case.

If any of these are missing, your petition can be dismissed without prejudice, but a dismissal still costs you time and may push you against the two-year statute of limitations in Section 440.19.

Where to Get the Form and How to Access It

The current revision of Form P-5.0900 is hosted on the OJCC Forms page as a fillable PDF, and the revision date is printed in the lower-left corner of page one. Always download a fresh copy each time you file, because the OJCC has revised the form several times since 2003 and old copies are routinely rejected by the clerk.

Represented parties must file through the e-JCC electronic filing system, which requires a free account, a verified email, and an attorney bar number. Pro se claimants may register for an e-JCC account using their Social Security number, or skip the portal entirely and mail or hand-deliver a paper PFB to the OJCC district office assigned by ZIP code of the accident.

The OJCC publishes a district office locator that lists addresses, phone numbers, and the assigned judge for every Florida county. Filing in the wrong district will not kill your case, because the clerk will transfer it, but it adds days to the 14-day carrier response clock.

Step-by-Step: How to Fill Out Form P-5.0900 Line by Line

The PFB is laid out in a fixed order. Work top to bottom and never skip a field, even one that looks irrelevant, because the clerk’s intake software flags blanks and bounces the petition back.

Caption: District Office and Judge

The top caption asks for the OJCC district office and, if known, the assigned Judge of Compensation Claims. In plain English, this tells the clerk which courthouse should receive the case and which judge should rule on it. Write the district office that covers the county where the accident happened, and leave the judge line blank if no case number exists yet, because cases are assigned by rotation.

For example, Marcus Reed, who fell from scaffolding in Tampa, writes Tampa District Office and leaves the judge line blank because this is his first PFB. If you have a P.O. Box but the accident happened in another county, the county of accident controls, not your mailing address. The most common mistake here is naming the wrong district based on where the claimant lives now, which delays assignment by 5 to 10 days. A common misconception is that the claimant gets to pick the judge — judges are assigned by the Clerk’s office under a published rotation, not by request.

OJCC Case Number

The case number block asks for the existing OJCC file number if the claimant has filed before on the same accident. The format is YY-XXXXXXX, where YY is the two-digit year the case was opened. Leave this box blank if this is the first PFB on the accident; the clerk will issue a new number.

For example, Aisha Brown, who already has an open 2025 case, writes 25-0123456 exactly as it appears on her last order. If you have two separate accidents on different dates, each accident gets its own case number, and you must file a separate PFB for each. The most common mistake is reusing an old, closed case number, which causes the new petition to be docketed in a closed file and ignored. A common misconception is that the carrier’s claim number and the OJCC case number are the same — they are not, and mixing them up is a top reason for dismissal.

Claimant’s Name, Address, and Personal Information

This block asks for the injured worker’s full legal name, mailing address, telephone number, date of birth, and Social Security number. Use the name on your Social Security card, not a nickname or married name unless that is the legal name. Format the date of birth as MM/DD/YYYY and the Social Security number as XXX-XX-XXXX.

For example, Janet Alvarez-Cruz writes her hyphenated legal name even though her driver’s license reads Janet Cruz, because the SSA record controls. If you live in a shelter or transitional housing, list the shelter address and add a note that mail should be sent there. The most common mistake is using a nickname like Jan instead of Janet, which causes the OJCC indexing system to fail to match your case to medical records. A common misconception is that you can skip the SSN for privacy reasons — the OJCC redacts it from the public docket but requires it for indexing.

Employer’s Name, Address, and FEIN

The employer block asks for the full legal name, mailing address, and Federal Employer Identification Number (FEIN) of the employer at the time of the accident. The FEIN is a nine-digit number formatted XX-XXXXXXX, and you can find it on a W-2 or pay stub. Use the legal name registered with the Florida Division of Corporations, not the trade name on the storefront.

For example, Carlos Mendoza writes Sunshine Hospitality LLC even though he worked at a restaurant called Casa Sol, because Sunshine Hospitality LLC is the entity on his W-2. If the employer is out of business, write Defunct next to the name and still list the last known address. The most common mistake is naming a parent company instead of the actual employing entity, which lets the wrong carrier deny coverage. A common misconception is that the staffing agency and the host employer are interchangeable — they are not, and you usually name both as co-employers.

Carrier or Servicing Agent Information

This block asks for the workers’ compensation carrier or servicing agent, its address, and the claim number. The carrier is the insurance company that pays benefits, and the servicing agent handles claims for self-insured employers. Get this information from the most recent benefit check stub, denial letter, or the Coverage Search tool at the Florida Department of Financial Services.

For example, Marcus Reed writes Travelers Indemnity Company, Hartford, CT address, and claim number FL-2025-44781. If the employer was uninsured, write Uninsured and the case will be routed to the Florida Workers’ Compensation Joint Underwriting Association or the Special Disability Trust Fund. The most common mistake is naming the third-party administrator (TPA) instead of the actual carrier, which means the real carrier never gets served. A common misconception is that the broker who sold the policy is the carrier — the broker has no role in claims.

Date and Description of Accident

This block asks for the date of accident in MM/DD/YYYY format and a brief description of how the injury happened. Keep the description factual and short, two or three sentences, focused on the mechanism of injury and the body parts hurt. Match the date and description to the DWC-1 First Report of Injury the employer filed.

For example, Aisha Brown writes 03/14/2025 and Claimant slipped on wet tile while restocking shelves and injured her lower back and right knee. If the accident is a repetitive trauma without a single date, use the date the doctor first connected the condition to work. The most common mistake is writing a long narrative full of legal conclusions like negligence or gross misconduct, which are not relevant in a no-fault system and invite motions to strike. A common misconception is that you must prove fault — Florida workers’ comp is no-fault, so just describe what happened.

Specific Benefits Requested

This is the heart of the petition and the field most often dismissed for vagueness. The block asks for a specific, itemized list of every benefit you want the judge to order, with dates, dollar amounts, and the statute or rule that supports each one. Section 440.192(2), Florida Statutes, requires this level of detail, and a generic all benefits owed will be struck.

For example, Janet Alvarez-Cruz writes: (1) TTD benefits from 04/01/2025 through 05/15/2025 at AWW of $720.00 per § 440.15(2); (2) Authorization of orthopedic surgeon Dr. Patel for right shoulder evaluation per § 440.13(2); (3) Reimbursement of $187.42 in mileage from 04/02/2025 to 05/10/2025 per Rule 69L-7.020. If you are unsure of the dollar amount, list the date range and the rate you believe applies, and the judge will calculate. The most common mistake is requesting future medical care without naming the doctor or the body part, which is too vague to enforce. A common misconception is that the judge will figure out what you need — the judge can only order what you specifically ask for.

Good-Faith Effort Statement

Rule 60Q-6.115 requires the claimant to certify that a good-faith effort was made to resolve each requested benefit with the carrier before filing. The block asks for the date of the contact, the name of the adjuster, and the method of contact (phone, email, letter). This certification is not optional, and missing it is independent grounds for dismissal under Rule 60Q-6.115.

For example, Carlos Mendoza writes Emailed adjuster Maria Lopez at Travelers on 05/20/2025 requesting authorization of MRI; no response received within 5 business days. If the carrier responded but denied, still list the date and the denial. The most common mistake is filing the same day you call the adjuster, which courts treat as no good-faith effort at all. A common misconception is that the good-faith requirement is waived for emergencies — it is not, but a one-day effort can be sufficient if medical urgency is documented.

Attorney Information and Signature

If a lawyer is filing for you, this block requires the attorney’s full name, Florida Bar number, firm name, address, telephone, and email. The attorney must also file a separate Notice of Appearance the same day. Pro se claimants leave this block blank and sign their own name on the signature line, with the date in MM/DD/YYYY format.

For example, Marcus Reed, filing pro se, writes Marcus Reed on the signature line and 05/22/2025 as the date, leaving the attorney block blank. If two attorneys at the same firm are working on the case, only the lead attorney signs, and the second files a separate Notice of Appearance. The most common mistake is an unsigned petition, which the clerk rejects on intake. A common misconception is that an electronic signature like /s/ Marcus Reed is invalid — it is valid in e-JCC and meets Rule 60Q-6.108.

Certificate of Service

The final block is the Certificate of Service, where the filer certifies that a copy of the PFB was served on the employer, the carrier, and any other party. List each recipient’s name, address, and the method of service (e-service, U.S. Mail, hand delivery). E-filing through e-JCC generates an automatic certificate, but you should still verify the service list.

For example, Aisha Brown writes Served via e-JCC on 03/20/2025: Sunshine Hospitality LLC, Travelers Indemnity Company, and Adjuster Maria Lopez. If you mail a paper PFB, attach a postage receipt as proof. The most common mistake is forgetting to serve the employer separately from the carrier, which voids service on the employer. A common misconception is that the OJCC clerk serves the parties for you — the clerk dockets the petition but does not serve it.

Three Filled-Out Examples Using Real Scenarios

Below are three full walk-throughs of the most common PFB fact patterns in Florida. Each follows one named claimant from caption to signature.

Scenario 1: Marcus Reed — Construction Fall, Unpaid TTD and MRI

Form Section	What Marcus Enters
District Office	Tampa District Office
OJCC Case Number	Blank — first PFB
Claimant Name	Marcus J. Reed
Date of Birth / SSN	07/12/1988 / XXX-XX-1234
Employer	BuildRight Construction Inc., FEIN 59-1234567
Carrier / Claim Number	Travelers Indemnity Co., FL-2025-44781
Date / Description of Accident	04/02/2025 — Fell from scaffold, fractured left wrist and lumbar strain
Specific Benefits Requested	TTD 04/03/2025–present at AWW $980; authorization of MRI of lumbar spine per Dr. Singh’s 04/20/2025 referral
Good-Faith Effort	Emailed adjuster J. Klein 04/25/2025; no response in 7 days
Signature	/s/ Marcus J. Reed, 05/02/2025

Scenario 2: Aisha Brown — One-Time Change of Physician

Form Section	What Aisha Enters
District Office	Orlando District Office
OJCC Case Number	25-0123456
Claimant Name	Aisha N. Brown
Date of Birth / SSN	11/03/1979 / XXX-XX-5678
Employer	Sunshine Hospitality LLC, FEIN 27-8899001
Carrier / Claim Number	Zenith Insurance Co., WC-25-99812
Date / Description of Accident	03/14/2025 — Slip on wet tile; lower back and right knee injuries
Specific Benefits Requested	One-time change of physician under § 440.13(2)(f); current authorized doctor unresponsive for 6 days
Good-Faith Effort	Letter to adjuster M. Lopez dated 05/10/2025; carrier failed to authorize alternate within 5 days
Signature	/s/ Aisha N. Brown, 05/16/2025

Scenario 3: Janet Alvarez-Cruz — PTD and Attorney’s Fees After MMI

Form Section	What Janet’s Attorney Enters
District Office	Miami District Office
OJCC Case Number	22-0044781
Claimant Name	Janet Alvarez-Cruz
Date of Birth / SSN	02/28/1965 / XXX-XX-9012
Employer	Atlantic Logistics Corp., FEIN 65-3344556
Carrier / Claim Number	Liberty Mutual, LM-22-55410
Date / Description of Accident	09/05/2022 — Forklift collision; cervical fusion, MMI 04/01/2025 with 28% PIR
Specific Benefits Requested	PTD benefits from 04/02/2025 forward per § 440.15(1); supplemental benefits per § 440.15(1)(f); claimant’s attorney’s fees and costs per § 440.34 and Castellanos
Good-Faith Effort	Email to adjuster R. Patel 05/18/2025 demanding PTD; denied 05/20/2025
Signature	/s/ Daniel Ortiz, Esq., FL Bar 0123456, 05/26/2025

How to File the Completed Form

The OJCC accepts PFBs through three channels, and each has its own rules, fees, and proof-of-filing.

E-filing through e-JCC is mandatory for attorneys and recommended for pro se filers. Go to the e-JCC portal, log in, upload the PDF, and submit. There is no filing fee for any PFB in Florida workers’ compensation, regardless of channel. The portal returns a stamped copy with a date-time receipt within seconds, and that receipt is your proof of filing.

Filing by U.S. Mail is allowed only for pro se claimants. Mail the signed original to the district office that covers the county of accident, addresses listed on the OJCC district office page. Use certified mail with return receipt so you have proof; processing time is typically 3 to 5 business days from delivery.

Filing in person is also allowed for pro se claimants at any OJCC district office during business hours. Bring two copies; the clerk stamps one and hands it back as your receipt. There is no fax filing channel — the OJCC eliminated fax intake years ago.

Whatever channel you use, keep the stamped copy for at least the life of the case plus seven years, because medical and wage disputes can be reopened.

What Happens After You File

Once the PFB is docketed, the OJCC clerk issues a case number (if new) and serves the carrier electronically. The carrier then has 14 days under Section 440.192(8) to pay, deny in writing, or otherwise respond. A failure to respond can trigger automatic acceptance of the requested benefit and an award of attorney’s fees.

Within 40 days, the assigned judge sets a mediation conference, which is mandatory under Section 440.25(1). If mediation fails, the case proceeds to a pretrial hearing and then a final hearing before the JCC, usually within 90 to 210 days of filing. The judge issues a written order, which can be appealed to the First District Court of Appeal within 30 days.

If the carrier pays the requested benefit before the response deadline, the petition is considered resolved as to that benefit and dismissed without prejudice. You can refile if the carrier later denies again.

Mistakes to Avoid When Filling Out the Form

• Vague benefit requests like all benefits owed — the judge cannot order what is not specified, and the petition will be struck.
• Wrong date of accident — even a one-day error breaks the link to the DWC-1 and can run the statute of limitations.
• Naming the trade name instead of the legal employer — service goes to the wrong entity and the case stalls.
• Listing the TPA as the carrier — the real carrier is never served and never responds.
• Skipping the good-faith effort statement — independent grounds for dismissal under Rule 60Q-6.115.
• Filing without medical support for surgery or MRI requests — the judge will deny on the merits even if the petition survives.
• Using an old form revision — the clerk’s intake software rejects superseded versions.
• Missing the Certificate of Service — service is invalid and the 14-day clock never starts.
• Pro se filer using nickname — the case fails to index against medical records.
• Filing on a closed case number — the petition lands in a closed file and is overlooked.
• Forgetting attorney’s Notice of Appearance — the petition is treated as unsigned.
• Mixing two accidents in one PFB — each accident requires its own petition and case number.

Do’s and Don’ts

• Do download a fresh form from the OJCC Forms page every time, because the revision date matters.
• Do itemize each benefit with dates, amounts, and the statute, because Section 440.192(2) demands specificity.
• Do document your good-faith effort in writing, because the rule requires proof, not just a phone call.
• Do serve the employer separately from the carrier, because they are distinct parties.
• Do keep a stamped copy for the entire life of the claim, because reopened cases need the original filing record.

• Do check the Coverage Search tool before naming the carrier, because carriers change mid-policy.

• Don’t copy a friend’s old PFB as a template, because forms and statutes change.

• Don’t include emotional narrative or fault language, because workers’ comp is no-fault.
• Don’t request benefits you cannot support with medical or wage records, because the carrier will move to dismiss.
• Don’t wait until the last week of the two-year window, because clerk errors can cost you the filing date.
• Don’t skip the SSN — the case will not index, and your medical records will not match.
• Don’t assume the clerk will fix typos, because the OJCC docket is a verbatim record.

Pros and Cons of Filing on Your Own vs. With Help

• Pro of pro se filing: No attorney’s fee comes out of your benefits, which can save thousands in PTD cases.
• Pro of pro se filing: You control the timing and content of every petition, which matters when you and the adjuster disagree on urgency.
• Pro of pro se filing: The OJCC publishes a pro se information packet and most district clerks will answer procedural questions.
• Pro of pro se filing: Mediation is informal, and many simple disputes (mileage, one-time change) settle without a lawyer.

• Pro of pro se filing: You build a personal record of your case that helps if you hire counsel later.

• Con of pro se filing: You will not know the case law (e.g., Castellanos, Westphal), which shapes attorney’s fee and PTD outcomes.

• Con of pro se filing: Vague benefit requests are the top dismissal reason, and a lawyer drafts them tighter.
• Con of pro se filing: Carriers and their defense counsel know procedural traps you may not.
• Con of pro se filing: A botched PFB can run the statute of limitations and end your case forever.
• Con of pro se filing: Claimant’s attorney fees in Florida are paid by the carrier when the claimant prevails under Section 440.34, so the cost is often zero out of pocket.

FAQs

Do I have to use Form P-5.0900, or can I write my own letter?

No. Rule 60Q-6.107 requires the OJCC-approved Petition for Benefits form, and a letter or homemade petition will be rejected by the clerk on intake.

Is there a filing fee for the PFB?

No. Florida workers’ compensation petitions are filed at no cost through any channel, including e-JCC, mail, or in person.

Can I file Form P-5.0900 if my accident happened five years ago?

No. Section 440.19 imposes a two-year statute of limitations from the date of accident, with a one-year extension from the last benefit paid; older claims are barred.

Do I write my full Social Security number in the SSN box?

Yes. The full nine-digit SSN is required for indexing, and the OJCC redacts it from the public docket automatically.

Should I list the staffing agency or the host employer in the employer block?

Yes. List both as co-employers when a staffing arrangement applies, because either can be the responsible party under Florida law.

Do I put the carrier’s claim number or the OJCC case number in the case number box?

No. Only the OJCC case number (format YY-XXXXXXX) goes in that box; the carrier’s claim number goes in the carrier block.

Can I file one PFB for two separate accidents?

No. Each date of accident requires its own petition and its own OJCC case number.

Do I need a lawyer to file Form P-5.0900?

No. Pro se filing is allowed, but Section 440.34 lets claimant’s attorney fees be paid by the carrier when you win, so representation is often free to you.

Is the good-faith effort statement really required?

Yes. Rule 60Q-6.115 makes it mandatory, and missing it is independent grounds for dismissal regardless of the merits.

Can I file Form P-5.0900 by fax?

No. The OJCC does not accept fax filings; use e-JCC, U.S. Mail, or in-person delivery only.

Do I need to attach medical records to the PFB?

No. Attachments are not required at filing, but you must produce supporting records at mediation or hearing.

What happens if the carrier ignores my petition?

Yes — the judge can grant the requested benefits by default and award attorney’s fees and costs under Section 440.34 if the carrier fails to respond within 14 days.