Forms for Private Self-Insured Employers
A Private Self-Insured Employer is required by law to provide important information to the Division annually. The Division has developed rules and adopted prescribed forms for self-insurers to use for reporting required information to the Division. A summary of relevant statutes, rules and forms are below. Please use the forms below to provide the required information to the Florida Self-Insurers Guaranty Association, Incorporated.
Forms:
- DFS-F2-SI-1, Application for Self-Insurance
- DFS-F2-SI-4F, Self-Insurer’s Surety Bond for FSIGA Members
- DFS-F2-SI-5, Self-Insurer Payroll Report
- DFS-F2-SI-6, Self-Insurer’s Irrevocable Letter of Credit
- DFS-F2-SI-8, Self-Insurance Employer Application for Drug-Free Work-Place Premium Credit Program
- DFS-F2-SI-9 Self-Insurance Certification of Workplace Safety Program Premium Credit
- DFS-F2-SI-10, Parental Guaranty and Corporate Resolution
- DFS-F2-SI-11, Indemnity Agreement
- DFS-F2-SI-17, Unit Statistical Report
- DFS-F2-SI-19, Certification of Servicing for Self-Insurers
- DFS-F2-SI-20, Report of Outstanding Workers’ Compensation Liabilities
Mailing Address:
- Florida Self-Insurers Guaranty Association, Incorporated
427 East Piedmont Drive, 2nd Floor
Tallahassee, Florida 32308
Contact FSIGA:
- Telephone Number: (850) 222-1882 or visit their website at https://fsiga.org