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Division Director

Tanner Holloman

Assistant Director

Andrew Sabolic


Workers' Compensation
200 East Gaines Street
Tallahassee, FL 32399-0318
Workers' Compensation Claims
(800) 342-1741
Workers' Compensation Exemption/ Compliance
(850) 413-1609

Forms for Private Self-Insured Employers

A Private Self-Insured Employer is required by law to provide important information to the Division annually. The Division has developed rules and adopted prescribed forms for self-insurers to use for reporting required information to the Division. A summary of relevant statutes, rules and forms are below. Please use the forms below to provide the required information to the Florida Self-Insurers Guaranty Association, Incorporated.

Forms

  • DFS-F2-SI-1, Application for Self-Insurance
  • DFS-F2-SI-4F, Self-Insurer’s Surety Bond for FSIGA Members
  • DFS-F2-SI-5, Self-Insurer Payroll Report
  • DFS-F2-SI-6, Self-Insurer’s Irrevocable Letter of Credit
  • DFS-F2-SI-8, Self-Insurance Employer Application for Drug-Free Work-Place Premium Credit Program
  • DFS-F2-SI-9, Self-Insurance Certification of Workplace Safety Program Premium Credit
  • DFS-F2-SI-10, Parental Guaranty and Corporate Resolution
  • DFS-F2-SI-11, Indemnity Agreement
  • DFS-F2-SI-17, Unit Statistical Report
  • DFS-F2-SI-19, Certification of Servicing for Self-Insurers
  • DFS-F2-SI-20, Report of Outstanding Workers’ Compensation Liabilities

Mailing Address:

  • Florida Self-Insurers Guaranty Association, Incorporated
    427 East Piedmont Drive, 2nd Floor
    Tallahassee, Florida 32308

Contact FSIGA: