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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) 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 S61ection, 2012 Capital Circle, S.66E., 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-insurer’s fiscal year. Copies of this form are available at the Division of Workers’ Compensation, Bureau of Monitoring and Audit, Self-Insurance S162ection, 2012 Capital Circle, S.167E., Hartman Building, Tallahassee, FL 32399-4224. The evaluation date shall not be prior to the end of the self-insurer’s 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 23069L-5.217, 231F.A.C.
232(2) FSIGA Members shall submit Form DFS-F2-SI-20 (Report of Outstanding Workers’ Compensation Liabilities), effective 08/09, to the:
249Florida Self-Insurers Guaranty Association, Inc.
2541427 E. Piedmont Dr., 2nd Floor
260Tallahassee, Florida 32308
263Rulemaking Authority 265440.38(1), 266(2), (3), 268440.385(6), 269440.525(2), 270440.591 FS. 272Law Implemented 274440.38(1), 275(2), (3), 277440.385(1), 278(3), (6), 280440.525 FS. 282History283–284New 3-9-10.
