Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-189 - WORKERS' COMPENSATION › Section 69O-189.003 - Workers' Compensation: Application and Audit Procedures

Current through Reg. 50, No. 138; July 16, 2024
(1)
(a)
				Each employer applying to a carrier in the voluntary market for workers'
				compensation coverage required by Section
				440.38, F.S., shall use Form
				ACORD 130 FL (rev. 2019/07), Florida Workers Compensation Application, which is
				hereby adopted and incorporated by reference. The form shall be completed and
				submitted to the carrier with which the employer wishes to contract for
				coverage.
(b) A carrier wishing to
				use its own application form shall submit the form electronically to the
				Florida Office of Insurance Regulation (Office) at
				http://www.floir.com/iportal, and receive approval prior to its use.
1. At a minimum the form shall require the
				employer to provide the following information:
a. Name, address, and legal status of the
				employer;
b. Federal employer
				identification number;
c. Type of
				business and contractor licensing number if the employer is a
				contractor;
d. Rating information
				including past and prospective payroll;
e. Estimated revenue;
f. Locations;
g. List of officers, sole proprietors and
				partners including their social security numbers (disclosure of social security
				number is voluntary; as an alternative, attach a copy of exclusion or inclusion
				forms filed with the state);
h.
				List of all employee names, employees' social security numbers and
				classifications (disclosure of social security numbers is voluntary; as an
				alternative, the latest RT form with class codes added can be used in lieu of a
				separate listing of employee names, employees' social security numbers and
				classifications);
i. Previous
				workers' compensation experience;
j. Former business names and predecessor
				companies for the last five years;
k. Former and current owners in the last five
				years;
l. All names under which the
				corporation operates; and,
m. Any
				other information necessary to enable the carrier to accurately underwrite the
				employer.
2. The
				application shall contain a statement that the filing of an application
				containing false, misleading, or incomplete information with the purpose of
				avoiding or reducing the amount of premiums for workers' compensation coverage
				is a felony of the third degree.
3.
				The application shall contain a sworn statement by the employer which complies
				with Section 92.525, F.S., attesting to the
				accuracy of the information submitted.
4. The application shall contain a sworn
				statement by the agent attesting which complies with Section
				92.525, F.S., that the agent
				explained to the employer or officer the classification codes that are used for
				premium calculations.
(c)
				Each employer applying for workers' compensation coverage in the Florida
				Workers' Compensation Joint Underwriting Association (FWCJUA) shall use Form
				ACORD 130 FL (2019/07) unless the FWCJUA files and receives approval by the
				Office of Insurance Regulation to use a different application form in
				accordance with paragraph (1)(b). The FWCJUA shall submit any addendum to the
				application to the Office and receive approval prior to using. The completed
				application and all addenda shall be submitted to the FWCJUA at the address on
				the form.
(d) Form ACORD 130 FL
				(rev. 2019/07) is available:
1. From ACORD at
https://www.acord.org/home
;
				and,
2. For inspection during
				regular business hours at the Office of Insurance Regulation, Larson Building,
				200 East Gaines Street, Tallahassee, Florida
				32399-0300.