jump to main menu jump to subject menu jump to content jump to footer

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

Former (Terminated) Self-Insurers

When a Private Self-Insurer Employer has no obligations under the Self-Insurance program, such as no open claims or outstanding liabilities, they are designated to be a Former Private Self-Insurer Employer. However, if the Former Private Self-Insurer Employer has chosen to voluntarily terminate from the Self-Insurance Program they are and have ongoing obligations, they 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) A Final Payroll Report is due 90 days after the cancellation date. 69L-5.203, F.A.C.
DFS-F2-SI-17 Word document (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 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.
Actuarial Report If you do not have Investment Grade Credit Ratings, this form must be submitted within 120 days after the end of their fiscal year or within 90 days of the date requested by the Department or the Association.
What is Investment Grade Credit Rating? A long-term issuer credit rating equal to or higher than "Baa3", "BBB-“, or "BBB-", issued by Moody’s Investors Service, Standard & Poor’s or Fitch Ratings, respectively. A credit rating assigned to a specific debt issue is not an acceptable substitute for a long-term issuer credit rating.
69L-5.210, 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