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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

Mandatory Filing Requirements

Active Self-Insurers

As an active Governmental Self-Insurer Employer, you are required to file important legible and complete documents to the Division timely to avoid being assessed civil penalties up to $10,000 outlined in Rule 69L-5.217, F.A.C. Please use the information outlined below as a helpful guideline to ensure the proper filing of these forms, reports or documents.

Form When to File Rule
DFS-F2-SI-5 Word document (Self-Insurer Payroll Report) 60 days after the Anniversary Rating Date.

What is an Anniversary Rating Date? An Anniversary Rating Date (ARD) is the effective month and day of the beginning of the self-insurance authorization and each anniversary thereafter unless a different date is established (69L-5.201, F.A.C.)
69L-5.203, F.A.C.
DFS-F2-SI-17 Word document (Unit Statistical Report) No later than 60 days after the evaluation date.

What is an evaluation date? An evaluation date is 6 months after the Anniversary Rating Date
69L-5.205, F.A.C.
DFS-F2-SI-19 Word document (Certification of Servicing for Self-Insurers) If a change in Servicing of Claims, this form must be filed within 30 days of that change.

If contracting with a Qualified Servicing Entity (QSE), this form must be filed within 30 days of entering into a servicing contract agreement.
  • If the expiring contract is renewed with the same QSE, this form must be filed 30 days after the expiration date of the contract being renewed.
  • If the contract is continuous or is greater than 3 years, this form must be filed no later than 3 years and 30 days from the date of submission of the prior SI-19.
69L-5.216, F.A.C.

Where to send?

Department of Financial Services
Division of Workers’ Compensation
Self-Insurance Section
200 East Gaines Street
Tallahassee, Florida 32399