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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 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 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
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.
DFS-F2-SI-20 Word document (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.

Where to send?

Florida Self-Insurers Guaranty Association, Incorporated, 1427 East Piedmont Drive, 2nd Floor, Tallahassee, Florida 32308.

How do I contact FSIGA?

Telephone Number: (850) 222-1882, Fax Number: (850) 222-2926 or visit their website at http://fsiga.org