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Florida Administrative Code (Last Updated: June 27, 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 |
1(1) An application for self-insurance shall be made on Form DFS-F2-SI-1 (Application for Self-Insurance), effective 08/09, as incorporated by reference. An application may be obtained at:
27Florida Self-Insurers Guaranty Association, Inc.
321427 E. Piedmont Dr., 2nd Floor
38Tallahassee, FL 32308
41or:
42www.fsiga.org
43(2) All applications for self-insurance shall be submitted in duplicate at least ninety (90) days prior to the desired effective date. Self-insurance effective dates shall be determined by the Department with consideration given to the date selected by the applicant and shall always be on the first of the month. However, on no occasion shall the effective date be more than six (6) months after the approval date.
111(3) The following information shall be submitted in duplicate with the application:
123(a) The most recent three (3) years of Financial Statements that conform to the requirements of Rule 14069L-5.225, 141F.A.C.
142(b) If the date of the latest Financial Statements is over six (6) months old at the time of application, interim financial statements, up to and including at least the latest fiscal quarter, must be included and must be certified as to their accuracy by a corporate officer, general partner or sole proprietor.
195(c) A completed Form DFS-F2-SI-19 (Certification of Servicing for Self-Insurers), effective 08/09, as previously incorporated by reference in Rule 5.216, F.A.C., detailing the proposed servicing arrangements and accompanying documentation that conforms to the requirements of Rule 23169L-5.216, 232F.A.C.
233(d) A list of all entities which the applicant intends to include under its self-insurance authorization in accordance with Rule 25369L-5.202, 254F.A.C., that includes the following information:
2601. Percentage of the applicant’s ownership interest in each entity,
2702. Federal Employer Identification Number (FEIN) of each entity,
2793. Addresses of each entity and its operating locations within the State of Florida, and
2944. Any fictitious names used by each entity within the State of Florida.
307(e) If the applicant is seeking approval as an Affiliated Self-Insurer, Form DFS-F2-SI-11 (Indemnity Agreement), effective 08/09, as previously incorporated by reference in Rule 33169L-5.214, 332F.A.C., shall be executed by an officer of each affiliated company to be included under the self-insurance authorization.
350(f) If the applicant is seeking approval using the Financial Statements of a parent company under Rule 36769L-5.215, 368F.A.C., Form DFS-F2-S1-10 (Parental Guaranty and Corporate Resolution for Self-Insured Subsidiary Entity), effective 08/09, as previously incorporated by reference in Rule 38969L-5.215, 390F.A.C., must be executed by a corporate officer of the parent company.
402(g) A list of corporate officers, general partners, or sole proprietor as applicable to the corporate structure of the applicant including the resident city and state and the full business address of each.
435(h) Certification by a corporate officer, general partner, or sole proprietor stating that the applicant, at the time of application, and until approval of the application, will maintain workers’ compensation insurance coverage in compliance with Section 471440.38(1)(a), F.S.
473(i) Certification by a corporate officer, general partner, or sole proprietor stating that the applicant has not experienced a material adverse change in its financial condition since the date of the latest provided Financial Statements.
508(j) A certificate of status from the applicant’s state of domicile, along with a certificate of status from the State of Florida, issued within the last six (6) months.
537(k) If the name of the entity has changed in the last three (3) years, documentation of the change as filed with the applicant’s state of domicile.
564(l) Experience modification promulgation worksheet for the current and two (2) preceding years as set forth in the NCCI Experience Rating Plan Manual for Workers’ Compensation and Employers Liability Insurance as previously incorporated by reference in Rule 60169L-5.201, 602F.A.C.
603(m) A Security Deposit that conforms to the requirements of Rule 61469L-5.218, 615F.A.C.
616(n) Proof of a Specific Excess Insurance Policy that conforms to Rule 62869L-5.219, 629F.A.C.
630(4) Upon receiving the application, the Association shall review the application. Any additional information needed to complete the application shall be requested within thirty (30) days.
656(5) The application is not complete for purposes of Section 666120.60, F.S., 668until all of the above requirements are met and the required documents are submitted to the Association. The Department shall not approve any application for self-insurance until the application is complete including the submission of the Security Deposit, proof of Specific Excess Insurance Policy and Certification of Servicing for Self-Insurers.
718Rulemaking Authority 720440.38(1), 721(2), (3), 723440.385(6), 724440.591 FS. 726Law Implemented 728440.38(1), 729(2), (3), 731440.385(1), 732(3), (6) FS. History–New 7363-9-10737.
