Mandatory Filing Requirements
Private Self-Insured Employers are required to file important information on an annual basis with the Division of Workers’ Compensation. A self-insurer is responsible for being aware of these obligations and their corresponding due dates. Florida statutes and rules specify the required information that must be filed, the form it must be provided on, and when the form is due. Self-insurers that do not file their information timely are subject to penalties (69L-5.217, F.A.C.). Please use the forms below for reporting required information.
Mandatory Filing Requirements Checklists
Active Private Self-Insured Employers (Timeline & Checklist)
| Mandatory Active Private Self-Insured Employers Filing Requirements | ||
| Filing Form | How to submit the form? | Contact for Submission |
| DFS-F2-SI-5 Self-Insurer Payroll Report (69L-5.203, F.A.C.) | Link to guide | START |
| DFS-F2-SI-17 Unit Statistical Report (69L-5.205, F.A.C.) | Link to guide SI-17 Reporting Training Manual - Excel File SI-17 Reporting Training Manual - Text File | START |
| DFS-F2-SI-19 Certification of Servicing for Self-Insurers (69L-216, F.A.C.) | Go to the Claims section of the START Portal | START |
| DFS-F2-SI-20 Report of Outstanding Workers’ Compensation Liabilities (69L-207, F.A.C.) | Mail to FSIGA | Florida Self-Insurers Guaranty Association Inc. 1427 East Piedmont Drive, 2nd Floor Tallahassee, Florida 32308 (850) 222-1882 www.fsiga.org |
| Specific Excess Insurance Policy (69L-5.207, F.A.C.) | Mail to FSIGA | Florida Self-Insurers Guaranty Association Inc. 1427 East Piedmont Drive, 2nd Floor Tallahassee, Florida 32308 (850) 222-1882 www.fsiga.org |
| Financial Statement (69L-5.209, F.A.C.) | Mail to FSIGA | Florida Self-Insurers Guaranty Association Inc. 1427 East Piedmont Drive, 2nd Floor Tallahassee, Florida 32308 (850) 222-1882 www.fsiga.org |
| Actuarial Report (as determined by FSIGA and the Division) (69L-5.210, F.A.C.) | Mail to FSIGA | Florida Self-Insurers Guaranty Association Inc. 1427 East Piedmont Drive, 2nd Floor Tallahassee, Florida 32308 (850) 222-1882 www.fsiga.org |
Former (Terminated) Private Self-Insured Employers with Open Claims (Timeline & Checklist)
| Mandatory Former (Terminated) Private Self-Insured Employers with Open Claims Filing Requirements | ||
| Filing Form | How to submit the form? | Contact for Submission |
| DFS-F2-SI-19 Certification of Servicing for Self-Insurers (69L-216, F.A.C.) | Go to the Claims section of the START Portal | START |
| DFS-F2-SI-20 Report of Outstanding Workers’ Compensation Liabilities (69L-207, F.A.C.) | Mail to FSIGA | Florida Self-Insurers Guaranty Association Inc. 1427 East Piedmont Drive, 2nd Floor Tallahassee, Florida 32308 (850) 222-1882 www.fsiga.org |
| Specific Excess Insurance Policy (69L-5.207, F.A.C.) | Mail to FSIGA | Florida Self-Insurers Guaranty Association Inc. 1427 East Piedmont Drive, 2nd Floor Tallahassee, Florida 32308 (850) 222-1882 www.fsiga.org |
| Financial Statement (69L-5.209, F.A.C.) | Mail to FSIGA | Florida Self-Insurers Guaranty Association Inc. 1427 East Piedmont Drive, 2nd Floor Tallahassee, Florida 32308 (850) 222-1882 www.fsiga.org |
| Actuarial Report (as determined by FSIGA and the Division) (69L-5.210, F.A.C.) | Mail to FSIGA | Florida Self-Insurers Guaranty Association Inc. 1427 East Piedmont Drive, 2nd Floor Tallahassee, Florida 32308 (850) 222-1882 www.fsiga.org |