As a Former 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 (Self-Insurer Payroll Report)||90 days after the cancellation date and must be submitted until the final payroll period has been reported.||69L-5.203, F.A.C.|
|DFS-F2-SI-17 (Unit Statistical Report)||No later than 60 days after the cancelation date and must be submitted until the loss data for the final period of authorization has been reported.||69L-5.205, F.A.C.|
|DFS-F2-SI-19 (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.
Department of Financial Services
Division of Workers’ Compensation
200 East Gaines Street, Tallahassee, Florida 32399