69O-190.074. Forms, Manuals and Instructions Adopted

(1) OIR forms adopted. The OIR forms set forth in paragraphs (a) through (aa) of this subsection, as well as the accompanying instructions to the forms, are hereby incorporated into rule chapter 69O-190, F.A.C., by reference. Copies of the forms are available from the Bureau of P & L Insurer Solvency, Office of Insurance Regulation, Tallahassee, Florida 32399-0300.

(a) OIR Form BSI-1, Application for Self-Insurance.

(b) OIR Form BSI-2, Employer Application for Group Coverage.

(c) OIR Form BSI-3, Membership Application.

(d) OIR Form BSI-3A, Self-Insurers Fund Member Application Monthly Change Sheet.

(e) OIR Form BSI-4, Revised Self-Insurers Surety Bond (Guaranty Fund Member).

(f) OIR Form BSI-4A, Self-Insurers Surety Bond (Guaranty Fund Non-Member).

(g) OIR Form BSI-4B, Self-Insurers Surety Bond.

(h) OIR Form BSI-5, Payroll Report, and the accompanying instructions.

(i) OIR Form BSI-6, Self-Insurance Letter of Credit.

(j) OIR Form BSI-11, Indemnity Agreement.

(k) OIR Form BSI-12, Drug-Free Workplace Program.

(l) OIR Form BSI-17, Unit Statistical Report, and the accompanying instructions.

(m) OIR Form BSI-19, Certification of Servicing for Self-Insurance.

(n) OIR Form BSI-20, Report of Workers’ Compensation Liabilities.

(o) OIR Form BSI-21, Breakdown of Policy Year Expenses.

(p) OIR Form BSI-22, Service Company Application.

(q) OIR Form BSI-23, Service Company Annual Report Form.

(r) OIR Form BSI-24, Quarterly Status Report.

(s) OIR Form BSI-24A, Preferred Payment Plan Quarterly Report.

(t) OIR Form BSI-26, Checklist for the Submission of Loss Reserve Reports.

(u) OIR Form BSI-27, Biographical Statement.

(v) OIR Form BSI-28, Quarterly Financial Statement.

(w) OIR Form BSI-29, Annual Financial Statement.

(x) OIR Form BSI-30, Report on Preferred Payment Plan.

(y) OIR Form BSI-31, Audit Procedures for Contractor/Independent Contractor Relationship.

(z) OIR Form BCM 201, Notice of Termination.

(aa) OIR Form BSI 206, Certificate of Self-Insurance, and the accompanying instructions.

(2) NAIC forms, instructions and manuals adopted. The NAIC forms, instructions and manual set forth in subparagraphs (a) through (e) of this subsection are hereby incorporated into rule chapter 69O-190, F.A.C., by reference. Copies of the forms are available from the National Association of Insurance Commissioners, 120 West 12th Street, Suite 1100, Kansas City, Missouri 64105, and are available for inspection during regular business hours at the Office at its headquarters in Tallahassee, Florida.

(a) The 1992 National Association of Insurance Commissioners Quarterly Statement, Fire and Casualty Companies Association Edition.

(b) The Jurat Page; Statutory Balance Sheet; Underwriting and Investment Exhibit – Income Statement; Cash Flow; Underwriting and Investment Exhibit Part 1, Part 1A, Part 2, Part 2A, Part 3, Part 3A and Part 4; Exhibit 1 – Analysis of Assets; Exhibit 2 – Analysis of Non-Admitted Assets; Notes to Financial Statements; Five Year Historical Data (NOTE: funds shall complete this form on a going forward basis); Schedule of Special Deposits; Schedule A Part 1; Schedule B; Schedule BA; Schedule C; Schedule D Part 1, Part 1A, Part 3, Part 4 and Part 5 (NOTE: only 4th quarter transactions need to be reported); Schedule DA Part 1; Schedule F – Part 1A (NOTE: any amounts in dispute must be disclosed), Schedule M; Schedule N; Schedule P, Part 1 Summary, Part 2 Summary, Part 3 Summary, Part 5 Summary, Interrogatories; Schedule X; Schedule Y of the 1992 National Association of Insurance Commissioners Annual Statement, Fire and Casualty Companies Association Edition.

(c) The NAIC’s Annual Statement Instructions, Property and Casualty, 1993 edition.

(d) The NAIC’s Accounting Practices and Procedures Manual for Property and Casualty Insurance Companies, 1993 edition.

(e) The NAIC’s Financial Condition Examiner’s Handbook, 1993 edition.

Rulemaking Authority 440.5705, 440.591, 624.4621 FS. Law Implemented 440.381, 440.5705, 624.316, 624.424, 614.4621 FS. History–New 12-19-93, Formerly 38F-5.074, 4-190.074.