RULE NO: RULE TITLE
69L-5.201: Definitions
69L-5.203: Payroll Reporting
69L-5.204: Maintenance of Payroll Records, Review and Audit
69L-5.205: Loss Data Reporting
69L-5.206: Maintenance of Loss Data Records, Review and Audit
69L-5.207: Outstanding Liabilities Reporting
69L-5.208: Maintenance of Outstanding Liabilities Records, Review and Audit
69L-5.210: Actuarial Reports
69L-5.211: Changes in Anniversary Rating Date
69L-5.213: Subsidiary, Affiliate and Location Reporting
69L-5.214: Indemnity Agreements for Affiliated Self-Insurers
69L-5.215: Parental Guaranty
69L-5.216: Provision of Benefits and Safe Working Environment by Self-Insurers
69L-5.217: Civil Penalties and Fines
69L-5.218: Security Deposits
69L-5.219: Excess Insurance
69L-5.220: Drug-Free Workplace Premium Credit Program
69L-5.221: Safety Program Premium Credit
69L-5.223: Election Process
69L-5.225: Requirements
69L-5.226: Application Process
69L-5.227: Alien Corporations Additional Requirements
69L-5.229: Application Process
69L-5.230: Contracting with a Qualified Servicing Entity
Definitions, Payroll Reporting, Maintenance of Payroll Records, Review and Audit, Loss Data Reporting, Maintenance of Loss Data Records, Review and Audit, Outstanding Liabilities Reporting, Maintenance of Outstanding Liabilities Records, Review and ...
- NOTICE OF CHANGENotice is hereby given that the following changes have been made to the proposed rule in accordance with subparagraph 120.54(3)(d)1., F.S., published in Vol. 35 No. 21, May 29, 2009 issue of the Florida Administrative Weekly.
GENERAL REQUIREMENTS
69L-5.201 Definitions.
(1) When used in these rules, the following words or terms shall mean:
(a) No change.
(b) Affiliated Self-Insurer Two or more entities affiliated by common majority ownership, as discussed in Rule 3, R13, D., of the NCCI Experience Rating Plan Manual for Workers Compensation and Employers Liability Insurance, which do not have a parent company to hold the self-insurance authorization, and which are approved by the Department to fund their workers co mpensation liabilities as prescribed in Section 440.38(1)(b), F.S. The NCCI Experience Rating Plan Manual for Workers Compensation and Employers Liability, 2003 Edition including updates through October 2008, is hereby incorporated by reference. A copy of the Manual may be obtained from the National Council on Compensation Insurance, Inc., Customer Service Center, 901 Peninsula Corporate Circle, Boca Raton, FL 33487, telephone (800)622-4123. A copy of the manual is also available for viewing 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.
(c) through (m) No change.
(n) FSIGA Member An individual self-insurer, as defined in Section 440.02(24)(a) and 440.38(1)(b), F.S., other than individual self-insurers which are public utilities or governmental entities, that received authorization from the Department to self-insure pursuant to Section 440.38(1)(b), F.S., including individual self-insurers for which the self-insurance authorization has been revoked or voluntarily surrendered.
(o) through (t) No change.
(u) Manual Premium Premium determined by multiplying the payroll (segregated into the proper workers compensation job classifications) times the manual rates per $100 of payroll in effect at the start of the payroll period covered, as further defined in the NCCI Basic Manual for Workers Compensation and Employers Liability Insurance. The NCCI Basic Manual for Workers Compensation and Employers Liability, 2001 Edition including updates through June 1, 2009 is hereby incorporated by reference. A copy of the Manual may be obtained from the National Council on Compensation Insurance, Inc., Customer Service Center, 901 Peninsula Corporate Circle, Boca Raton, FL 33487, telephone (800)622-4123. A copy of the manual is also available for viewing 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.
(v) through (z) No change.
(aa) Standard Premium As defined in Rule 3, R33, 20., of the NCCI Basic Manual for Workers Compensation and Employers Liability Insurance. The NCCI Basic Manual for Workers Compensation and Employers Liability Insurance, 2001 Edition including updates through June 1, 2009 has been previously incorporated by reference.
(bb) Successor Entity Any person, business entity, or group of persons or business entities, which holds or acquires legal or beneficial title to the majority of the assets or the majority of the shares of a Current Self-Insurer or Former Self-Insurer, pursuant to Sections 440.38(1)(b)3. and 440.385(1)(b), F.S.
69L-5.203 Payroll Reporting.
Self-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 69L-5.217, F.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.
(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.
(2) Former Self-Insurers shall submit this report until the final payroll period has been reported.
(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.
(a) Governmental Entities and Public Utilities shall submit Form DFS-F2-SI-5 (Self-Insurer Payroll Report), effective 08/09, to the:
Department of Financial Services
Division of Workers Compensation
Bureau of Monitoring and Audit/Self-Insurance
200 East Gaines Street
Tallahassee, Florida 32399-4224
(b) FSIGA Members shall submit Form DFS-F2-SI-5 (Self-Insurer Payroll Report), effective 08/09, to the:
Florida Self-Insurers Guaranty Association, Inc.
1427 E. Piedmont Dr., 2nd Floor
Tallahassee, Florida 32308
69L-5.204 Maintenance of Payroll Records, Review and Audit.
(1) The payroll records of all Current Self-Insurers and Former Self-Insurers shall be open for inspection and audit by the Department, or its Authorized Representative, during regular business hours. Self-insurers are required to maintain payroll records that reflect a true and accurate division by the classification codes contained in the SCOPES of Basic Manual Classifications and the NCCI Basic Manual for Workers Compensation and Employers Liability Insurance so the proper classification code for each employee may be determined. The SCOPES of Basic Manual Classifications effective June 1, 2008 is hereby incorporated by reference. A copy of the SCOPES of Basic Manual Classifications may be obtained from the National Council on Compensation Insurance, Inc., Customer Service Center, 901 Peninsula Corporate Circle, Boca Raton, FL 33487, telephone (800)622-4123. A copy of the manual is also available for viewing 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. The NCCI Basic Manual for Workers Compensation and Employers Liability Insurance, 2001 Edition, including updates through June 1, 2009, is previously incorporated by reference into Rule 69L-5.201, F.A.C.
If such records are not maintained, then the entire payroll shall be presumed to be within the classification code to which the highest manual rate is applicable. To ensure their availability for audit purposes, the records shall be retained for five (5) years from the end of the payroll period. The location of these records shall be provided to the Department upon submission of the application for self-insurance and updated within fifteen (15) days of any relocation.
(2) No change.
69L-5.205 Loss Data Reporting.
Current Self-Insurers and Former Self-Insurers shall submit loss data for all entities covered under the self-insurance authorization on Form DFS-F2-SI-17 (Unit Statistical Report), effective 08/09, as incorporated by reference, or the electronic equivalent provided by the Department. 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. Failure to submit the required loss data forms or material understatement or concealment of data shall constitute good cause for revocation of the self-insurance authorization in addition to civil penalties specified in Rule 69L-5.217, F.A.C.
(1) The Division or the Association shall, within at least ten (10) days prior to the evaluation date, advise each self insurer of the covered periods for the submission of the loss data.
(2) Current Self-Insurers will complete Form DFS-F2-SI-17 (Unit Statistical Report), effective 08/09, or the electronic equivalent of Form DFS-F2-SI-17 (Unit Statistical Report), effective 08/09, by submitting loss data for the current evaluation year and the prior two (2) evaluation years.
(3) No change.
(4) The completed Form DFS-F2-SI-17 (Unit Statistical Report), effective 08/09, or the electronic equivalent of Form DFS-F2-SI-17 (Unit Statistical Report), effective 08/09, shall be mailed or transmitted to the Division or the Association no later than sixty (60) days after the evaluation date.
(a) Governmental Entities who are unable to transmit an electronic version of Form DFS-F2-SI-17 (Unit Statistical Report), effective 08/09, shall mail the completed Form DFS-F2-SI-17 (Unit Statistical Report), effective 08/09, no later than 60 days after the evaluation date to the:
Department of Financial Services
Division of Workers Compensation
Bureau of Monitoring and Audit/Self-Insurance
200 East Gaines Street
Tallahassee, Florida 32399-4224
(b) FSIGA Members who are unable to transmit the electronic version of Form DFS-F2-SI-17 (Unit Statistical Report), effective 08/09, shall mail the completed Form DFS-F2-SI-17 (Unit Statistical Report), effective 08/09, to:
Florida Self-Insurers Guaranty Association, Inc.
1427 E. Piedmont Dr., 2nd Floor
Tallahassee, Florida 32308
(5) The Division will promulgate the experience modification using the NCCI Basic Manual for Workers Compensation and Employers Liability Insurance and the NCCI Experience Rating Plan Manual for Workers Compensation and Employers Liability Insurance. The NCCI Experience Rating Plan Manual for Workers Compensation and Employers Liability Insurance, 2003 Edition, including updates through October 2008, and the NCCI Basic Manual for Workers Compensation and Employers Liability Insurance, 2001 Edition, including updates through June 1, 2009, are previously incorporated by reference into Rule 69L-5.201, F.A.C.
(6) through (7) No change.
69L-5.206 Maintenance of Loss Data Records, Review and Audit.
(1) All records supporting the submitted Form DFS-F2-SI-17 (Unit Statistical Report), effective 08/09, as previously incorporated by reference in Rule 69L-5.205, F.A.C., or its electronic equivalent shall be open for inspection and audit by the Department or its Authorized Representative, during regular business hours. 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. Self-insurers are required to maintain loss records that reflect a true and accurate division by the classification codes, status type, and injury codes contained in the NCCI Workers Compensation Statistical Plan Manual and the NCCI Basic Manual for Workers Compensation and Employers Liability Insurance so the proper classification code, status type, and injury code for each accident may be determined. The Workers Compensation Statistical Plan Manual 2008 edition including updates through April 1, 2009 is hereby incorporated by reference. A copy of the Manual may be obtained from the National Council on Compensation Insurance, Inc., Customer Service Center, 901 Peninsula Corporate Circle, Boca Raton, FL 33487, telephone (800)622-4123. A copy of the manual is also available for viewing 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. The NCCI Basic Manual for Workers Compensation and Employers Liability Insurance, 2001 Edition, including updates through June 1, 2009, is previously incorporated by reference into Rule 69L-5.201, F.A.C.
To ensure their availability for audit purposes, the records shall be retained for five (5) years from the last date the claims data was used for calculation of the experience modification. The location of these records shall be provided to the Department upon submission of the application for self-insurance and updated within fifteen (15) days of any relocation.
(2) No change.
69L-5.207 Outstanding Liabilities Reporting.
(1) Current Self-Insurers and Former Self-Insurers, other than Governmental Entities, shall report their outstanding self-insured workers compensation liabilities for all entities covered under the self-insurance authorization on Form DFS-F2-SI-20 (Report of Outstanding Workers Compensation Liabilities), effective 08/09, as incorporated by reference. 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. This includes all outstanding liabilities of Former Self-Insurers for which the Current Self-Insurer is the Successor Entity. Form DFS-F2-SI-20 (Report of Outstanding Workers Compensation Liabilities), effective 08/09, shall be accompanied by a loss run substantiating all amounts reported on the form, be signed by an Authorized Representative of the Self-Insurer or its Qualified Servicing Entity, and be submitted no later than 120 days after the end of the self-insurers fiscal year. 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. The evaluation date shall not be prior to the end of the self-insurers latest fiscal year. Failure to submit the required Form DFS-F2-SI-20 (Report of Outstanding Workers Compensation Liabilities), effective 08/09, or material understatement or concealment of loss reserves, shall constitute good cause for revocation of the self-insurance authorization in addition to civil penalties specified in Rule 69L-5.217, F.A.C.
(2) FSIGA Members shall submit Form DFS-F2-SI-20 (Report of Outstanding Workers Compensation Liabilities), effective 08/09, to the:
Florida Self-Insurers Guaranty Association, Inc.
1427 E. Piedmont Dr., 2nd Floor
Tallahassee, Florida 32308
69L-5.208 Maintenance of Outstanding Liabilities Records, Review and Audit.
(1) All records supporting Form DFS-F2-SI-20, (Report of Outstanding Workers Compensation Liabilities), effective 08/09, shall be open for inspection and audit by the Department, the Association, or their Authorized Representative, during regular business hours. Each self-insurer is required to maintain all records supporting Form DFS-F2-SI-20 (Report of Outstanding Workers Compensation Liabilities), effective 08/09. To ensure their availability for audit purposes, the records shall be retained for five (5) years after closing of a claims file.
(2) No change.
69L-5.210 Actuarial Reports.
(1) Current Self-Insurers and Former Self-Insurers, other than Governmental Entities, that do not have Investment Grade Credit Ratings shall be required to submit Actuarial Reports within 120 days after the end of their fiscal year or within 90 days of the date requested by the Department or the Association.
(a) No change.
(b) If requested by the Department or the Association in order to determine the value of the current loss reserves, any Current Self-Insurer or Former Self-Insurer, other than a Governmental Entity, shall be required to submit an Actuarial Report.
(2) The Department or the Association shall require that the Actuarial Report include a forecast of loss reserves to a future date for Current Self-Insurers.
(3) No change.
69L-5.211 Changes in Anniversary Rating Date.
(1) No change.
(2) Upon receipt of the written request, the Division or the Association shall advise the self-insurer in writing within thirty (30) days as to the effective date of the change, using the NCCI Workers Compensation Experience Rating Plan Manual for Workers Compensation and Employers Liability Insurance as previously incorporated by reference in Rule 69L-5. 201, F.A.C., to determine this date.
69L-5.213 Subsidiary, Affiliate and Location Reporting.
(1) No change.
(2) Current Self-Insurers shall annually provide a written statement of the accuracy of their subsidiary, affiliate and location information. Such statement shall be signed by an officer of the Current Self-Insurer.
(3) No change.
69L-5.214 Indemnity Agreements for Affiliated Self-Insurers.
Affiliated Self-Insurers must execute a new Form DFS-F2-SI-11 (Indemnity Agreement), effective 08/09, as incorporated by reference, within thirty (30) days of changes in the affiliates included under the self-insurance authorization. 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. Form DFS-F2-SI-11 (Indemnity Agreement), effective 08/09, shall be executed by an officer of each affiliated entity to be included under the self-insurance authorization. The executed form shall be submitted to the:
Florida Self-Insurers Guaranty Association, Inc.
1427 E. Piedmont Dr., 2nd Floor
Tallahassee, Florida 32308
69L-5.215 Parental Guaranty.
Notwithstanding any other provisions of these Rules to the contrary, if a parent company that directly or indirectly owns 100% of a Current Self-Insurer, Former Self-Insurer or applicant for self-insurance elects to execute Form DFS-F2-SI-10 (Parental Guaranty and Corporate Resolution for Self-Insured Subsidiary Entity), effective 08/09, as incorporated by reference, then:
(1) through (5) No change.
(6) Copies of Form DFS-F2-SI-10 (Parental Guaranty and Corporate Resolution for Self-Insured Subsidiary Entity), effective 08/09, 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.
69L-5.216 Provision of Benefits and a Safe Working Environment by Self-Insurers.
(1) It shall be the sole responsibility of Current Self-Insurers and Former Self-Insurers to provide for competent persons to service their self-insurance program in the areas of claims adjusting, safety engineering and loss control. This shall be done through either the use of their own employees, who are determined by the Department to have experience in these areas, or by contracting with a Qualified Servicing Entity approved by the Department to provide these services. A list of Qualified Servicing Entities may be obtained by contacting the Department at:
Department of Financial Services
Division of Workers Compensation
Bureau of Monitoring and Audit/Self-Insurance
200 East Gaines Street
Tallahassee, Florida 32399-4224
(2) Current Self-Insurers and Former Self-Insurers choosing to use their own employees to provide these services must obtain prior approval from the Department and shall submit Form DFS-F2-SI-19 (Certification of Servicing for Self-Insurers), effective 08/09, as incorporated by reference, within thirty (30) days of a change in servicing arrangement and at least every three (3) years thereafter. Resumes of employees with experience in these areas must be provided for approval.
(3) Current Self-Insurers or Former Self-Insurers contracting with Qualified Servicing Entities must file Form DFS-F2-SI-19 (Certification of Servicing for Self-Insurers), effective 08/09, within thirty (30) days of entering into a servicing contract.
(a) For Governmental Entities, Form DFS-F2-SI-19 (Certification of Servicing for Self-Insurers), effective 08/09, shall be obtained from and submitted to the:
Department of Financial Services
Division of Workers Compensation
Bureau of Monitoring and Audit/Self-Insurance
200 East Gaines Street
Tallahassee, Florida 32399-4224
(b) For FSIGA Members, Form DFS-F2-SI-19 (Certification of Servicing for Self-Insurers), effective 08/09, shall be obtained from and submitted to the:
Florida Self-Insurers Guaranty Association, Inc.
1427 E. Piedmont Dr., 2nd Floor
Tallahassee, Florida 32308
(4) Failure to submit the required Form DFS-F2-SI-19 (Certification of Servicing for Self-Insurers), effective 08/09, shall constitute good cause for revocation of the self-insurance authorization in addition to civil penalties specified in Rule 69L-5.217, F.A.C.
(5) No change.
69L-5.217 Civil Penalties and Fines.
(1) No change.
(2) A request for an extension of time to file a form, report or document shall be made in writing by the self-insurer or its Qualified Servicing Entity and shall be postmarked no later than fifteen (15) days prior to the due date of the form, report or document. Extensions shall be granted in writing and notice provided to the self-insurer or Qualified Servicing Entity. Such extension shall establish a new one-time due date subject to the same provision for late filing.
(a) For forms, reports, or documents, other than Actuarial Reports requested by the Association and Financial Statements, extensions shall be granted by the Division if proof is supplied by the self-insurer or Qualified Servicing Entity that circumstances entirely beyond the control of the self-insurer or its Qualified Servicing Entity have made it impossible to file in a timely manner. Such circumstances shall be limited to:
1. through 3. No change.
(b) No change.
(c) For Financial Statements, extensions shall be granted by the Division if proof is supplied by the self-insurer that circumstances entirely beyond the control of the self-insurer have made it impossible to file in a timely manner. Extensions may be granted for up to sixty (60) days if the self-insurer submits draft Financial Statements and provides evidence that the reason for the delay in submittal is entirely beyond the control of the self-insurer. For extensions beyond sixty (60) days from the original due date, circumstances shall be limited to:
1. through 3. No change.
(3) No change.
(4) Fines for Delinquent Payment of Assessments Assessments payable to the Florida Self-Insurers Guaranty Association, Inc., not postmarked by the due date, shall incur a fine of $100 or 5% of the assessment due, whichever is greater, per month until paid. Total penalties under this section shall not exceed the greater of $25,000 or 50% of the total assessment amount.
(5) through (6) No change.
69L-5.218 Security Deposits.
(1) through (6) No change.
(7) If the self-insurer is a FSIGA Member, the Security Deposit must be submitted to and executed in favor of the Association. The Security Deposit shall be held by the Association or the Department exclusively for the benefit of workers compensation claimants. The Security Deposit shall not be subject to assignment, execution, attachment, or any legal process whatsoever, except as necessary to guarantee the payment of workers compensation benefits under Chapter 440, F.S.
For FSIGA Members, security deposit forms DFS-F2-SI-4F (Self-Insurers Surety Bond for FSIGA Member) and Form DFS-F2-SI-6 (Self-Insurers Irrevocable Letter of Credit) can be obtained from and shall be submitted to the:
Florida Self-Insurers Guaranty Association, Inc.
1427 E. Piedmont Dr., 2nd Floor
Tallahassee, Florida 32308
(8) A Security Deposit shall consist of, at the option of the employer:
(a) A surety bond on Form DFS-F2-SI-4F (Self-Insurers Surety Bond for FSIGA Member), effective 08/09, as incorporated by reference, which shall be issued by a corporation surety authorized to transact surety business by the Florida Department of Financial Services, Office of Insurance Regulation, and whose financial strength and size ratings from A. M. Best Company are not less than A and V respectively, or
(b) An irrevocable letter of credit on Form DFS-F2-SI-6 (Self-Insurers Irrevocable Letter of Credit), effective 08/09, as incorporated by reference, which shall be issued by a financial institution located within the State of Florida and the deposits of which are insured through the Federal Deposit Insurance Corporation.
(9) No change.
69L-5.219 Excess Insurance.
(1) Current Self-Insurers, other than Governmental Entities, shall maintain a Specific Excess Insurance Policy. Such policy shall have a workers compensation limit of not less than $50,000,000.
(a) The self-insured retention of Specific Excess Insurance Policies shall be as follows:
1. No change.
2. A higher self-insured retention shall be allowed, if approved by the Department. The Department shall consider the Current Self-Insurers financial strength in its review of the requested self-insured retention.
(b) through (g) No change.
(h) Provides that, in the event any commutation is effected, the Department shall have the right to direct that such sum either be placed in trust for the benefit of the injured employee or employees entitled to such future payments of compensation or be invested in approved securities and deposited with the Department to insure such future payments of compensation to the employee or employees entitled thereto. Said commutation must contain a provision that the Department may order that the monies due under the terms of the Specific Excess Insurance Policy be paid directly to the injured employee or a trustee appointed by the Department. Such an action shall be ordered only if the Department determines that it is necessary to ensure continued benefits to the injured employee.
(i) through (k) No change.
(2) through (3) No change.
(4) If requested by the Association or the Division to verify compliance with these rules or to evaluate a self-insurers financial condition, self-insurers shall provide copies of excess insurance policies to support estimated excess insurance recoveries included in their Actuarial Reports provided to the Association or the Division.
69L-5.220 Drug-Free Workplace Premium Credit Program.
(1) In order for self-insurers to receive up to a five percent (5%) credit on the computation of premiums used in the determination of the assessments for the Workers Compensation Administration Trust Fund, the Special Disability Trust Fund and the Florida Self-Insurers Guaranty Association, Inc., they must state that they have established a drug-free workplace in accordance with Sections 440.101 and 440.102, F.S.
(2) The application must be completed using Form DFS-F2-SI-8 (Self-Insured Employer Application for Drug-Free Workplace Premium Credit Program), effective 08/09, as incorporated by reference, and shall be filed annually, sixty (60) days prior to their Anniversary Rating Date. 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. The completed Form DFS-F2-SI-8 (Self-Insured Employer Application for Drug-Free Workplace Premium Credit Program), effective 08/09, shall be mailed to the:
Department of Financial Services
Division of Workers Compensation
Assessments Unit
200 East Gaines Street
Tallahassee, FL 32399-4221
(3) Applications not received prior to the Anniversary Rating Date shall be applied pro rata as of the date the certification is received at the Division.
69L-5.221 Safety Program Premium Credit.
(1) In order for self-insurers to receive up to a two percent (2%) credit on the computation of premiums used in the determination of the assessments for the Workers Compensation Administration Trust Fund, the Special Disability Trust Fund and the Florida Self-Insurers Guaranty Association, Inc., they must state that they have established a workplace safety program in accordance with Section 440.1025, F.S.
(2) The statement must be completed using Form DFS-F2-SI-9 (Self-Insurer Certification of Workplace Safety Program Premium Credit) effective 08/09, as incorporated by reference, and shall be filed annually sixty (60) days prior to their Anniversary Rating Date. 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. The completed Form DFS-F2-SI-9 (Self-Insurer Certification of Employer Workplace Safety Program Premium Credit) effective 08/09, shall be mailed to the:
Department of Financial Services
Division of Workers Compensation
Assessments Unit
200 East Gaines Street
Tallahassee, Florida 32399-4221
(3) Certifications not received prior to the Anniversary Rating Date shall be applied pro rata as of the date the certification is received at the Division.
Rulemaking Authority 440.1025, 440.38(1), (2), (3), 440.385(6), 440.591 FS. Law Implemented 440.1025, 440.38(1), (2), (3), 440.385(1), (3), (6) FS. HistoryNew________.
69L-5.223 Election Process.
(1) The state and its boards, bureaus, departments, and agencies and all of its political subdivisions which employ labor, and the state universities that are electing to self-insure pursuant to Section 440.38(6), F.S., shall submit to the Division for review at least ninety (90) days prior to the preferred effective date of self-insured status, the following information:
(a) No change.
(b) Application for Governmental Self-Insurance, Form DFS-F2-SI-1G, effective 08/09, as incorporated by reference;
(c) Application for Governmental Self-Insurance Estimated Payroll, Form DFS-F2-SI-GEP, effective 08/09, as incorporated by reference;
(d) Certification of Servicing for Self-Insurers, Form DFS-F2-SI-19, effective 08/09, as previously incorporated by reference in Rule 69L-5.216, F.A.C.; and
(e) NCCI Workers Compensation Experience Modification Promulgation Worksheet for the current and two (2) preceding years, as set forth in the National Council on Compensation Insurance (NCCI) Experience Rating Plan Manual for Workers Compensation and Employers Liability Insurance. The NCCI Experience Rating Plan Manual for Workers Compensation and Employers Liability Insurance, 2003 Edition, including updates through October 2008, is previously incorporated by reference into Rule 69L-5.201, F.A.C.
The notification, forms and supporting documentation can be obtained from and shall be submitted to the:
Department of Financial Services
Division of Workers Compensation
Bureau of Monitoring and Audit/Self-Insurance
200 East Gaines Street
Tallahassee, Florida 32399-4224
(2) No change.
Rulemaking Authority 440.38(1), (2), (3), 440.385(6), 440.591 FS. Law Implemented 440.38(1), (2), (3), 440.385(1), (3), (6) FS. HistoryNew_________.
69L-5.225 Requirements.
(1) through (6) No change.
(7) Provision of Benefits and a Safe Working Environment The applicant shall provide a completed Form DFS-F2-SI-19 (Certification of Servicing for Self-Insurers), effective 08/09, as previously incorporated by reference in Rule 69L-5.216, F.A.C., detailing the proposed servicing arrangements and accompanying documentation that conforms to the requirements of Rule 69L-5.216, F.A.C.
(8) No change.
69L-5.226 Application Process.
(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:
Florida Self-Insurers Guaranty Association, Inc.
1427 E. Piedmont Dr., 2nd Floor
Tallahassee, FL 32308
or:
www.fsiga.org
(2) No change.
(3) The following information shall be submitted in duplicate with the application:
(a) through (b) No change.
(c) A completed Form DFS-F2-SI-19 (Certification of Servicing for Self-Insurers), effective 08/09, as previously incorporated by reference in Rule 69L-5.216, F.A.C., detailing the proposed servicing arrangements and accompanying documentation that conforms to the requirements of Rule 69L-5.216, F.A.C.
(d) No change.
(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 69L-5.214, F.A.C., shall be executed by an officer of each affiliated company to be included under the self-insurance authorization.
(f) If the applicant is seeking approval using the Financial Statements of a parent company under Rule 69L-5.215, F.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 69L-5.215, F.A.C., must be executed by a corporate officer of the parent company.
(g) through (k) No change.
(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 69L-5.201, F.A.C.
(m) through (n) No change.
(4) through (5) No change.
69L-5.227 Alien Corporations Additional Requirements.
(1) An opinion from an attorney, with a minimum of three years experience in international law, that states that the Alien Corporations country of domicile has substantially similar laws with respect to the jurisdiction of the Department and the Courts of the State of Florida for the purpose of securing timely payment of all current and future workers compensation claims of the Alien Corporation.
(2) through (3) No change.
69L-5.229 Application Process.
(1) Application to become a Qualified Servicing Entity shall be made on Form DFS-F2-SI-22 (Qualified Servicing Entity Application), effective 08/09, incorporated by reference. Entities may apply to become a Qualified Servicing Entity in any or all of the following: claims-adjusting, loss control or safety engineering. The application shall be submitted to the Division at least ninety (90) days prior to the desired effective date. The application may be obtained at:
Department of Financial Services
Division of Workers Compensation
Bureau of Monitoring and Audit/Self-Insurance
200 East Gaines Street
Tallahassee, FL 32399-4224
(a) Entities that are not insurance companies licensed to write workers compensation insurance by the Florida Office of Insurance Regulation shall include the following in the application package:
1. A completed Form DFS-F2-SI-22 (Qualified Servicing Entity Application), effective 08/09, as incorporated by reference.
2. No change.
(b) A completed Form DFS-F2-SI-27 (Biographical Statement and Affidavit), effective 08/09, as incorporated by reference, for each owner and member of management, along with a brief resume. 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.
(c) through (f) No change.
(g) A statement signed by an officer of the company that the Qualified Servicing Entity utilizes only authorized rehabilitation services pursuant to Section 440.491(7), F.S.,
(h) through (j) No change.
(2) Entities that are insurance companies licensed to write workers compensation insurance by the Florida Office of Insurance Regulation shall include the following in the application package:
(a) A completed Form DFS-F2-SI-22 (Qualified Servicing Entity Application), effective 08/09, and
(b) No change.
(3) through (4) No change.
69L-5.230 Contracting with a Qualified Servicing Entity.
(1) Each Qualified Servicing Entity shall file Form DFS-F2-SI-19 (Certification of Servicing for Self-Insurers), effective 08/09, as previously incorporated by reference in Rule 69L-5.216, F.A.C., within thirty (30) days of entering into a contract for servicing.
(a) For Governmental Entities, Form DFS-F2-SI-19 (Certification of Servicing for Self-Insurers), effective 08/09, shall be obtained from and submitted to the:
Department of Financial Services
Division of Workers Compensation
Bureau of Monitoring and Audit/Self-Insurance
200 East Gaines Street
Tallahassee, FL 32399-4224
(b) For FSIGA Members, Form DFS-F2-SI-19 (Certification of Servicing for Self-Insurers), effective 08/09, shall be obtained from and submitted to the:
Florida Self-Insurers Guaranty Association, Inc.
1427 E. Piedmont Drive, 2nd Floor
Tallahassee, FL 32308
(2) through (10) No change.
(11) Each Qualified Servicing Entity shall file with the Division no later than March 1 of each year, Form DFS-F2-SI-23 (Qualified Servicing Entity Annual Report Form), effective 08/09, as incorporated by reference. A copy of Form DFS-F2-SI-23 (Qualified Servicing Entity Annual Report Form), effective 08/09, is available at the:
Department of Financial Services
Division of Workers Compensation
Bureau of Monitoring and Audit/Self-Insurance
200 East Gaines Street
Tallahassee, FL 32399-4224
(12) through (13) No change.
The remainder of the rule reads as previously published.
