As a Current Private Self-Insurer Employer, you are required to file important legible and complete documents to the Florida Self-Insurers Guaranty Association, Incorporated 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)||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.)
|DFS-F2-SI-17 (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
|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.
|DFS-F2-SI-20 (Outstanding Workers’ Compensation Liabilities)||No later than 120 days after the end of the self-insurer’s fiscal year.||69L-5.207, F.A.C.|
|Specific Excess Insurance Policy||Within 90 days of the effective date of the policy. This is a onetime filing reported during your application process.||69L-5.219, F.A.C.|
|Financial Statement||No later than 120 days after the end of your fiscal year.||69L-5.209, F.A.C.|
Florida Self-Insurers Guaranty Association, Incorporated, 1427 East Piedmont Drive, 2nd Floor, Tallahassee, Florida 32308.
Telephone Number: (850) 222-1882, Fax Number: (850) 222-2926 or visit their website at http://fsiga.org