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Florida Administrative Code (Last Updated: October 28, 2024) |
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69. Department of Financial Services |
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69L. Division of Workers' Compensation |
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69L-5. Rules For Self-Insurers Under The Workers' Compensation Act |
169L-5.203 2Payroll Reporting.
4Self-Insurers shall report payroll data for all entities covered under the self-insurance authorization using Form DFS-F2-SI-5 (Self-Insurer Payroll Report), effective 08/09, as incorporated by reference. Failure to submit the required payroll reports, understatement or concealment of payroll, or the misrepresentation of employee duties so as to avoid proper classification shall constitute good cause for revocation of the self-insurance authorization in addition to civil penalties specified in Rule 7169L-5.217, 72F.A.C. Copies of this form are available at the Division of Workers’ Compensation, Bureau of Monitoring and Audit, Self-Insurance Section, 2012 Capital Circle, S.E., Hartman Building, Tallahassee, FL 32399-4224.
101(1) Current Self-Insurers and Former Self-Insurers shall complete Form DFS-F2-SI-5 (Self-Insurer Payroll Report), effective 08/09, by submitting payroll by classification code for the latest completed period beginning on the Anniversary Rating Date.
133(2) Former Self-Insurers shall submit this report until the final payroll period has been reported.
148(3) Current Self-Insurers shall submit Form DFS-F2-SI-5 (Self-Insurer Payroll Report), effective 08/09, no later than sixty (60) days after their Anniversary Rating Date. Former Self-Insurers shall submit their final Form DFS-F2-SI-5 (Self-Insurer Payroll Report), effective 08/09, no later than ninety (90) days after the revocation or voluntary termination of the self-insurance authorization.
200(a) Governmental Entities and Public Utilities shall submit Form DFS-F2-SI-5 (Self-Insurer Payroll Report), effective 08/09, to the:
217Department of Financial Services
221Division of Workers’ Compensation
225Bureau of Monitoring and Audit/Self-Insurance
230200 East Gaines Street
234Tallahassee, Florida 32399-4224
237(b) FSIGA Members shall submit Form DFS-F2-SI-5 (Self-Insurer Payroll Report), effective 08/09, to the:
251Florida Self-Insurers Guaranty Association, Inc.
2561427 E. Piedmont Dr., 2nd Floor
262Tallahassee, Florida 32308
265Rulemaking Authority 267440.38(1), 268(2), (3), 270440.385(6), 271440.525(2), 272440.591 FS. 274Law Implemented 276440.38(1), 277(2), (3), 279440.385(1), 280(3), (6), 282440.525 FS. 284History285–286New 3-9-10.
