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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 |
169L-5.223 2Election Process.
4(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 35440.38(6), F.S., 37shall submit to the Division for review at least ninety (90) days prior to the preferred effective date of self-insured status, the following information:
61(a) Copy of document(s) through which the entity is organized or authorized to operate as a Governmental Entity, including articles of incorporation, grant of authority, or charter, if applicable;
90(b) Application for Governmental Self-Insurance, Form DFS-F2-SI-1G, effective 08/09, as incorporated by reference;
103(c) Application for Governmental Self-Insurance Estimated Payroll, Form DFS-F2-SI-GEP, effective 08/09, as incorporated by reference;
118(d) Certification of Servicing for Self-Insurers, Form DFS-F2-SI-19, effective 08/09, as previously incorporated by reference in Rule 69L136-1375.216, F.A.C.; and
140(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 20569L-5.201, 206F.A.C.
207The notification, forms and supporting documentation can be obtained from and shall be submitted to the:
223Department of Financial Services
227Division of Workers’ Compensation
231Bureau of Monitoring and Audit/Self-Insurance
236200 East Gaines Street
240Tallahassee, Florida 32399-4224
243(2) Upon receipt of the notification and supporting documentation from an entity defined within the scope of Section 261440.38(6), F.S., 263the Division shall provide to the entity the “Insurer Code #” pursuant to Rule 27769L-3.002, 278F.A.C., prior to the effective date of self-insured status for compliance with filing requirements of Rule Chapters 69L-3 and 69L-7, F.A.C.
299Rulemaking Authority 301440.38(1), 302(2), (3), 304440.385(6), 305440.591 306F307S. Law Implemented 310440.38(1), 311(2), (3), 440314.385(1), (3), (6) F318S. History320–321New 3-9-10.
