reglab/statecodes huggingface dataset:
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.0033 - Electronic Filing of Workers' Compensation Forms (Transferred)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					 440.185(2),
					 440.593 FS. Law Implemented
					 440.593
					 FS.
New 1-10-05, Amended 6-30-14, Transferred to
					  69L-56.402.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.0035 - Injured Worker Informational Brochure

Current through Reg. 50, No. 138; July 16, 2024
In accordance with subsection
				   440.185(4),
				  F.S., the insurer or its claim administrator on behalf of the insurer shall
				  mail to the injured worker an informational brochure, Form DFS-F2-DWC-60,
				  "Important Workers' Compensation Information For Florida's Workers" or Form
				  DFS-F2-DWC-61
http://www.flrules.org/Gateway/reference.asp?No=Ref-04179
,
				  "Informacion Importante De Seguro De Indemnizacion Por Accidentes De Trabajo
				  Para Los Trabajadores De La Florida," as adopted in rule
				   69L-3.025, F.A.C., as applicable
				  within 3 business days after notification of the injury or
				  illness.
Rulemaking Authority
					 440.185(4),
					 440.593 FS. Law Implemented
					 440.593
					 FS.
New 1-10-05, Amended
					 6-30-14.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.0036 - Employer Informational Brochure

Current through Reg. 50, No. 138; July 16, 2024
In accordance with subsection
				   440.185(4),
				  F.S., the insurer or its claim administrator on behalf of the insurer shall
				  annually mail to the employer an informational brochure, Form DFS-F2-DWC-65,
				  "Important Workers' Compensation Information For Florida's Employers" or Form
				  DFS-F2-DWC-66, "Informacion Importante Del Seguro De Indemnizacion Por
				  Accidentes De Trabajo Para Los Empleadores De La Florida," as adopted in rule
				   69L-3.025, F.A.C., as
				  applicable.
Rulemaking Authority
					 440.185(4),
					 440.593 FS. Law Implemented
					 440.593
					 FS.
New 1-10-05, Amended
					 6-30-14.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.004 - First Report of Injury or Illness: Employer's Responsibility to Record and Report Accidents (Transferred)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					 440.185(2), (5),
					 (9),
					 440.19,
					 440.35,
					 449.591 FS. Law Implemented
					  440.185(2), (3),
					 (5),
					  440.207(2),
					  440.35 FS.
New 8-30-79, Amended 12-23-80, 11-5-81, 6-12-84, Formerly
					 38F-3.04, Amended 1-1-87, 4-11-90, 1-30-91, 11-8-94, Formerly 38F-3.004,
					 4L-3.004, Amended 1-10-05, 6-30-14, Transferred to
					  69L-56.401.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.0045 - First Report of Injury or Illness: Claim Administrator's Responsibility to Record and Report Accidents (Transferred)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					 440.14(5),
					 440.185(2), (5),
					 (9),
					 440.20(3),
					 440.207(2),
					 440.51(8), (9),
					 440.591 FS. Law Implemented
					  440.12,
					  440.185(2), (5),
					 (9),
					  440.20(2)(a),
					 (6),
					  440.41 FS.
New 4-11-90, Amended 1-30-91, 11-8-94, 12-5-96, Formerly
					 38F-3.0045, 4L-3.0045, Amended 1-10-05, 6-30-14, Transferred to
					  69L-56.4011.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.0046 - Wage Statement: Employer's and Claim Administrator's Responsibility to Record and Report Wages

Current through Reg. 50, No. 138; July 16, 2024
(1) Employer's
				responsibility: The employer shall report wage information to the claim
				administrator on Form DFS-F2-DWC-1a, as adopted in rule
				 69L-3.025, F.A.C., pursuant to
				section  440.14, F.S. The employer shall
				provide the claim administrator all required wage information within 14 days of
				the employer's knowledge of a "lost time" or a "medical only to lost time
				case."
(2) Claim administrator's
				responsibility: The claim administrator shall compare Forms DFS-F2-DWC-1 and
				DFS-F2-DWC-1a, as adopted in rule
				 69L-3.025, F.A.C., to confirm
				that the employee name or other identifying information, and the date of injury
				on the two forms are consistent.
Rulemaking Authority
					 440.14,
					 440.185(5),
					 440.591 FS. Law Implemented
					 440.12(2),
					 440.185(5), (9)
					 FS.
New 1-10-05, Amended 3-16-09,
					 6-30-14.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.0047 - Fraud Statement

Current through Reg. 50, No. 138; July 16, 2024
(1) An injured
				employee or any other party making a claim shall provide his or her personal
				signature attesting that they have reviewed, understand and acknowledge the
				fraud statement as specified in section
				 440.105(7),
				F.S.
(2) A party who makes claims
				for services provided to the claim administrator on a recurring basis may make
				one personally signed attestation to the claim administrator as required by
				section  440.105(7),
				F.S., which will satisfy the requirement for all claims submitted to the claim
				administrator for the calendar year in which the attestation is
				submitted.
Rulemaking Authority
					 440.105(7),
					 440.591 FS. Law Implemented
					 440.105(7)
					 FS.
New 1-10-05, Amended
					 6-30-14.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.0085 - Funeral Expense Bills (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					 440.591 FS. Law Implemented
					 440.16,
					 440.20(2)
					 FS.
New 10-30-79, Formerly 38F-3.15, Amended 11-5-81, Formerly
					 38F-3.085, Amended 4-11-90, 1-30-91, 11-8-94, Formerly 38F-3.0085, 4L-3.0085,
					 Repealed 1-10-05.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.009 - Injuries that Qualify as Grievous Bodily Harm of a Nature that Shocks the Conscience

Current through Reg. 50, No. 138; July 16, 2024
For purposes of determining the compensability of
				  employment-related posttraumtic stress disorder for first responders and
				  correctional officers, the following injuries qualify as grievous bodily harm
				  of a nature that shocks the conscience:
(1) Decapitation (full or partial),
(2) Degloving,
(3) Enucleation,
(4) Evisceration,
(5) Exposure of one or more of the following
				internal organs:
(a) Brain,
(b) Heart,
(c) Intestines,
(d) Kidneys,
(e) Liver, or
(f) Lungs
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.0091 - Notice of Action/Change (Transferred)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					  440.185,
					  440.20 (3),
					 440.591 FS. Law Implemented
					 440.15(3)(d)2., 440.185,
					 440.20,
					  440.207(2),
					  440.51(8), (9) 
					 FS.
New 1-30-91, Amended 11-8-94, Formerly 38F-3.0091,
					 4L-3.0091, Amended 1-10-05, 6-30-14, Transferred to
					  69L-56.404.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.012 - Notice of Denial (Transferred)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					 440.185(5),
					 440.20(3),
					 440.591 FS. Law Implemented
					 440.12(2),
					 440.14,
					 440.192(8),
					 440.20(2), (4), (9),
					 (15)(f),
					 440.207(2)
					 FS.
New 10-30-79, Amended 11-5-81, 5-30-82, 6-12-84, Formerly
					 38F-3.12, Amended 4-11-90, 1-30-91, 11-8-94, Formerly 38F-3.012, 4L-3.012,
					 Amended 1-10-05, 6-30-14, Transferred to
					  69L-56.4012.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.016 - Claim Cost Report (Transferred)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					 440.185,
					 440.591 FS. Law Implemented
					 440.185,
					 440.51(6)
					 FS.
New 10-30-79, Amended 11-5-81, Formerly 38F-3.16, Amended
					 4-11-90, 1-30-91, 11-8-94, Formerly 38F-3.016, 4L-3.016, Amended 1-10-05,
					 6-30-14, Transferred to
					  69L-56.4013.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.017 - Notice of Apportionment of Medical Reimbursement Due to a Pre-Existing Condition(s)

Current through Reg. 50, No. 138; July 16, 2024
For dates of injury occurring on or after 10/1/2003, if the
				  claim administrator decides to apportion payment of a medical benefit pursuant
				  to section  440.15(5),
				  F.S., it shall send Form DFS-F2-DWC-12, Notice of Denial, or a letter to the
				  employee explaining its apportionment decision, no later than three (3)
				  business days after the date the claims-handling entity notified a health care
				  provider that payment of the medical benefit will be apportioned pursuant to
				  subsection  69L-7.602(5),
				  F.A.C. Compliance with this rule is independent of and does not satisfy the
				  notification requirement pursuant to subsection
				   69L-7.602(5),
				  F.A.C.
Rulemaking Authority
					 440.185(5),
					 440.591 FS. Law Implemented
					 440.12(2),
					 440.15(3), (5)
					 FS.
New 10-10-12, Amended
					 6-30-14.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.018 - Wage Loss Benefits Due to Permanent Impairment (Dates of Accident August 1, 1979 through December 31, 1993) (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					 440.15(3)(b),
					 440.185(4),
					 (10),
					 440.41,
					 440.591 FS. Law Implemented
					 440.15(3), 440.185(4), 440.185(10) (1993)
					 FS.
New 10-30-79, Amended 11-5-81, 5-30-82, 6-12-84, Formerly
					 38F-3.18, Amended 4-11-90, 1-30-91, 11-8-94, 11-11-96, Formerly 38F-3.018,
					 4L-3.018, Amended 1-10-05, 6-30-14, Repealed
					 10-28-15.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.019 - Wage Loss Benefits for Temporary Partial Disability (Dates of Accident August 1, 1979 through December 31, 1993) (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					 440.15(4)(e),
					 440.185(4),
					 (10),
					 440.41,
					 440.591 FS. Law Implemented
					 440.15(4)(b), 440.185(4), 440.185(10) (1993), 440.20 (1993)
					 FS.
New 10-30-79, Amended 11-5-81, Formerly 38F-3.19, Amended
					 4-11-90, 1-30-91, 11-8-94, 11-11-96, Formerly 38F-3.019, 4L-3.019, Amended
					 1-10-05, 6-30-14, Repealed 10-28-15.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.0191 - Temporary Disability Benefits (Dates of Accident January 1, 1994 through September 30, 2003) (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					 440.15(2)(d),
					 (4)(a),
					 440.185(4),
					 (5),
					 440.20(3),
					 440.591 FS. Law Implemented
					  440.15(2), (4),
					  440.185(4),
					 (5),
					  440.20(3) 
					 FS.
New 11-8-94, Formerly 38F-3.0191, 4L-3.0191, Amended
					 1-10-05, 6-30-14, Repealed 10-28-15.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.01915 - Temporary Partial Disability Benefits (Dates of Accident on or After October 1, 2003)

Current through Reg. 50, No. 138; July 16, 2024
(1) Letter requirement
				- The claim administrator shall mail an informational letter to the employee
				and employer within 5 business days after the claim administrator's knowledge
				of the employee's release to restricted work. This letter shall explain the
				employee's eligibility for temporary partial disability benefits and the
				obligation to report earnings. These earnings would include the receipt of any
				of the following: salary, wages, Unemployment Compensation benefits, or Social
				Security benefits. The letter to the employee must contain at least the
				following:
"Your doctor has released you to return to work, but because
				  of your work-related accident, you have been given restrictions on the type of
				  work you can now do. Because you have not reached maximum medical improvement
				  (the date after which your doctor says your injury will probably not get
				  better), you may continue receiving workers' compensation benefits
				  approximately every two weeks if you are not able to earn at least 80% of the
				  weekly wages you were making before your injury.
(a) These benefits, called Temporary Partial
				Disability benefits, will be paid until:
1.
				You reach maximum medical improvement or can return to work without
				restrictions;
2. You receive the
				maximum of 104 weeks allowed by law for either Temporary Total Disability
				benefits, Temporary Partial Disability benefits or Training and Education
				Temporary Total benefits, or 104 weeks for the combined benefits; or
3. You earn 80% or more of the weekly wages
				you were making at the time of your accident.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.0192 - Impairment Income Benefits (Dates of Accident January 1, 1994 through September 30, 2003) (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					 440.591 FS. Law Implemented
					 440.15(3)
					 FS.
New 11-8-94, Formerly 38F-3.0192, 4L-3.0192, Amended
					 1-10-05, 6-30-14, Repealed 10-28-15.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.01925 - Impairment Income Benefits (Dates of Accident on or After October 1, 2003)

Current through Reg. 50, No. 138; July 16, 2024
(1) The initial payment of impairment income
				benefits shall include payment for all full weeks of entitlement since the date
				of maximum medical improvement up to the time the initial payment is made.
				After the employee has reached maximum medical improvement, the claim
				administrator shall make the initial payment of impairment income benefits no
				later than the 14th day after the claim administrator has knowledge of the
				employee's permanent impairment rating.
(2) Impairment income benefits shall be paid
				in biweekly installments pursuant to sections
				 440.15(3)(c) and
				(g), F.S. (2003).
(3) Impairment income benefits may not be
				offset by social security or unemployment compensation benefits received by the
				employee.
Rulemaking Authority
					 440.15(3)(f),
					 440.591 FS. Law Implemented
					 440.15(3)(f)
					 FS.
New 1-10-05, Amended
					 6-30-14.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.0193 - Supplemental Income Benefits (Dates of Accident January 1, 1994 through September 30, 2003) (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority 440.15(3)(b)5.,
					 440.591 FS. Law Implemented
					 440.15(3),
					 440.20(3),
					 440.491
					 FS.
New 11-8-94, Formerly 38F-3.0193, 4L-3.0193, Amended
					 1-10-05, 6-30-14, Repealed 10-28-15.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.0194 - Permanent Total and Permanent Total Supplemental Benefits for Dates of Accident Prior to October 1, 2003

Current through Reg. 50, No. 138; July 16, 2024
(1)
(a) Permanent total benefits paid for
				injuries occurring prior to July 1, 1955, shall not be made in excess of 700
				weeks. Permanent total benefits paid for injuries occurring on or after July 1,
				1955, shall continue during the continuance of the employee's
				entitlement.
(b) When a permanently
				and totally disabled employee re-establishes an earning capacity and undertakes
				a trial period of re-employment pursuant to section
				 440.15(1)(d),
				F.S., the employee may be eligible for impairment income and supplemental
				benefits pursuant to section
				 440.15(3),
				F.S.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.01945 - Permanent Total and Permanent Total Supplemental Benefits for Dates of Accident on or After October 1, 2003

Current through Reg. 50, No. 138; July 16, 2024
(1)
				Permanent total benefits paid for injuries occurring on or after October 1,
				2003, shall cease at age 75. If it is determined that the injury prevented the
				employee from working sufficient quarters to be eligible for social security
				benefits under 42 U.S.C.
				Section 402 or
				423, benefits will continue to be
				paid in accordance with the requirements of chapter 440, F.S. If the accident
				occurred on or after the employee reaches age 70, benefits shall be payable
				during the continuance of permanent total disability, not to exceed 5 years
				from the date of permanent total disability.
(2) Permanent total benefits paid for
				injuries occurring on or after October 1, 2003, shall continue during the
				continuance of the employee's entitlement.
(a) When a permanently and totally disabled
				employee re-establishes an earning capacity and undertakes a trial period of
				re-employment pursuant to section
				 440.15(1)(d),
				F.S., the employee may be eligible for impairment income benefits pursuant to
				section  440.15(3),
				F.S.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.0195 - Forms (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					 440.13(11)(b),
					 440.591 FS. Law Implemented
					 440.13(11)(b), 440.15(1)(f)1., (10) FS.
New 10-2-94, Amended 6-4-97, Formerly 38F-24.029,
					 38F-3.0195, 4L-3.0195, Repealed
					 1-10-05.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.0212 - Monthly Risk Class/SIC Code Report (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					 440.591 FS. Law Implemented
					 440.59
					 FS.
New 11-8-94, Formerly 38F-3.0212, 4L-3.0212, Repealed
					 1-10-05.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.0213 - Aggregate Claims Administration Change Report (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					 440.591 FS. Law Implemented
					 440.59
					 FS.
New 11-8-94, Formerly 38F-3.0213, 4L-3.0213, Amended
					 1-10-05, Repealed by Section 11, Chapter 2012-34, Laws of Florida
					 7-1-12.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.0214 - Aggregate Defense Attorney Fee Report (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					 440.345 FS. Law Implemented
					 440.345
					 FS.
New 11-25-96, Formerly 38F-3.0214, 4L-3.0214, Repealed
					 1-10-05.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.025 - Forms

Current through Reg. 50, No. 138; July 16, 2024
(1) The following forms are to be used with
				this rule chapter and are hereby incorporated by reference:
(a)
Form DFS-F2-DWC-1
3/16/09
First Report of Injury or Illness
(b)
Form IA-1
1/1/02
Workers' Compensation - First Report of Injury or
							 Illness, 
							 © International
							 Association of Industrial Accident Boards and Commissions (IAIABC) 2002. Note:
							 Form IA-1 is to be used only by those entities approved to transmit electronic
							 First Reports of Injury to the Division
(c)
Form DFS-F2-DWC-1a
3/16/09
Wage Statement
(d)
Form DFS-F2-DWC-4
3/16/09
Notice of Action/Change
(e)
Form DFS-F2-DWC-12
3/16/09
Notice of Denial
(f)
Form DFS-F2-DWC-13
3/16/09
Claim Cost Report
(g)
Form DFS-F2-DWC-14
3/16/09
Request for Social Security Disability Benefit
							 Information
(h)
Form DFS-F2-DWC-19
3/16/09
Employee Earnings Report
(i)
Form DFS-F2-DWC-30
3/16/09
Authorization and Request for Unemployment
							 Compensation Information
(j)
Form DFS-F2-DWC-33
3/16/09
Permanent Total Offset Worksheet
(k)
Form DFS-F2-DWC-35
3/16/09
Permanent Total Supplemental Worksheet
(l)
Form DFS-F2-DWC-40
3/16/09
Statement of Quarterly Earnings for Supplemental
							 Income Benefits
(m)
Form DFS-F2-DWC-60
03/10
Important Workers' Compensation Information for
							 Florida's Workers
(n)
Form DFS-F2-DWC-61
02/14
Informacion Importante De Seguro De Indemnizacion Por
							 Accidentes De Trabajo Para Los Trabajadores De La Florida
http://www.flrules.org/Gateway/reference.asp?No=Ref-04179
(o)
Form DFS-F2-DWC-65
03/10
Important Workers' Compensation Information for
							 Florida's Employers
(p)
Form DFS-F2-DWC-66
03/10
Informacion Importante Del Seguro De Indemnizacion
							 Por Accidentes De Trabajo Para Los Empleadores De La Florida
(2)
				The Division will not supply the forms promulgated under this chapter, but will
				make sample forms available on the Division's web site:
http://www.myfloridacfo.com/division/WC/
.
Rulemaking Authority
					 440.15,
					 440.185,
					 440.20,
					 440.591 FS. Law Implemented
					  440.02,
					  440.05,
					  440.102,
					  440.107,
					  440.12,
					  440.13,
					  440.14,
					  440.15,
					  440.16,
					  440.185,
					  440.19,
					  440.191,
					  440.192,
					  440.20(2), (3),
					  440.21,
					  440.34(3),
					  440.345,
					  440.35,
					  440.40,
					  440.491,
					  440.51(6), (9) 
					 FS.
New 4-11-90, Amended 1-30-91, 11-8-94, 11-11-96, 11-25-96,
					 Formerly 38F-3.025, 4L-3.025, Amended 1-10-05, 3-16-09, 11-30-10,
					 6-30-14.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-4 - ASSESSMENTS › Section 69L-4.001 - Reporting Assessment Information and Paying Assessments

Current through Reg. 50, No. 138; July 16, 2024
(1) Form DFS-F7-DWC-2133, Carrier and
				Self-Insurance Fund Quarterly Premium Report, Premium Documentation
				Spreadsheet, Carrier Profile and Instructions (Eff. 2/2014), is hereby
				incorporated by reference and required for use by all carriers and
				self-insurance funds for quarterly reporting to the Department of Financial
				Services, Division of Workers' Compensation (Division) of assessments owed to
				the Workers' Compensation Administration Trust Fund (WCATF) and Special
				Disability Trust Fund (SDTF) and payment of those assessments to the Division
				pursuant to subsections
				 440.49(9)  and
				 440.51(1)-(5),
				F.S.
(2) The Division will provide
				Form DFS-F7-DWC-2133 or its electronic equivalent to all active carriers and
				self-insurance funds authorized to write the workers' compensation line of
				insurance in Florida that are known to it not later than five (5) days prior to
				the expiration of each calendar quarter. All carriers and self-insurance funds
				required to pay assessments to the WCATF and SDTF must return accurately
				completed Form DFS-F7-DWC-2133 to the Division, in accordance with instructions
				included in the form, and pay all assessments to the WCATF and SDTF that are
				due not later than thirty (30) days from the end of the calendar quarter for
				which the form applies. No carrier or self-insurance fund required to report
				assessment information to the Division and pay assessments to the WCATF and
				SDTF is excused from those obligations because it did not receive Form
				DFS-F7-DWC-2133 from the Division. Form DFS-F7-DWC-2133 can be obtained by
				contacting the following email address: Assessments.Unit@MyFloridaCFO.com or
https://www.flrules.org/Gateway/reference.asp?No=Ref-04178
.
Rulemaking Authority 440.49(9)(b)1.,
					 440.51(2), (6),
					 440.591 FS. Law Implemented
					 440.49(9),
					 440.50,
					 440.51(1)-(5)
					 FS.
New 6-22-14.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-4 - ASSESSMENTS › Section 69L-4.002 - Offsets for Dividends and Premium Refunds

Current through Reg. 50, No. 138; July 16, 2024
(1) For purposes of its quarterly WCATF
				assessments under this rule, a carrier or self-insurance fund may offset from
				its total of premiums collected during the quarter all amounts actually paid or
				credited to policyholders for dividends and returned premiums during the
				quarter regardless of the calendar year the policies incepted for which the
				dividends or returned premiums apply. For purposes of its quarterly SDTF
				assessments under this rule, a carrier or self-insurance fund may offset from
				its total amount of premiums written during the quarter, all amounts actually
				paid or credited to policyholders for dividends and returned premiums during
				the quarter regardless of the calendar year the policies incepted for which the
				dividends or premiums apply.
(2) In
				the event a carrier or self-insurance fund is determined by the division to
				have overpaid its annual WCATF or SDTF assessment, the amount of any actual
				overpayment deposited into the State Treasury may, at the option of the carrier
				or fund, be carried forward as a dollar-for-dollar credit against future
				assessment liabilities; or be refunded by the division. No carrier or
				self-insurance fund shall be entitled to credits that exceed the assessment
				amounts actually paid for the specific calendar year to which the assessments
				apply.
Rulemaking Authority 440.49(9)(b)1.,
					 440.51(2), (6),
					 440.591,
					 624.308 FS. Law Implemented
					  215.26,
					  440.49(9),
					  440.50,
					  440.51(1)-(5),
					  624.5094 FS.
New 6-22-14.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-5 - RULES FOR SELF-INSURERS UNDER THE WORKERS' COMPENSATION ACT › Section 69L-5.101 - Definitions (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					 440.38(2)(b),
					 440.591 FS. Law Implemented
					 440.38(1)(b)
					 FS.
New 10-1-82, Amended 12-17-85, Formerly 38F-5.30, Amended
					 3-11-87, 8-28-91, 12-19-93, Formerly 38F-5.030, Amended 5-19-97, Formerly
					 38F-5.101, 4L-5.101, Amended 3-8-06, Repealed
					 3-9-10.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-5 - RULES FOR SELF-INSURERS UNDER THE WORKERS' COMPENSATION ACT › Section 69L-5.102 - General Requirements (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					 440.38(2)(b),
					 440.591 FS. Law Implemented
					 440.38(6)
					 FS.
New 5-19-97, Formerly 38F-5.102, 4L-5.102, Amended 3-8-06,
					 10-29-06, Repealed 3-9-10.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-5 - RULES FOR SELF-INSURERS UNDER THE WORKERS' COMPENSATION ACT › Section 69L-5.103 - Application (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					 440.38(2)(b),
					 440.591 FS. Law Implemented
					 440.38(1)(b)
					 FS.
New 5-19-97, Formerly 38F-5.103, 4L-5.103, Amended 3-8-06,
					 Repealed 3-9-10.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-5 - RULES FOR SELF-INSURERS UNDER THE WORKERS' COMPENSATION ACT › Section 69L-5.104 - Alternate Method of Application (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					 440.591,
					 440.38(2)(b)
					 FS. Law Implemented 440.38(1)(b),
					 (2)(b)
					 FS.
New 10-1-82, Amended 12-25-84, Formerly 38F-5.44, Amended
					 2-3-88, 6-12-91, 12-19-93, 5-14-96, Formerly 38F-5.044, Amended 5-19-97,
					 Formerly 38F-5.104, 4L-5.104, Repealed
					 3-9-10.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-5 - RULES FOR SELF-INSURERS UNDER THE WORKERS' COMPENSATION ACT › Section 69L-5.105 - General Requirements (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					 440.38(1)(b),
					 (2)(b) FS. Law Implemented
					 440.38(1)(b),
					 (2)(b)
					 FS.
New 5-19-97, Formerly 38F-5.105, 4L-5.105, Repealed
					 3-9-10.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-5 - RULES FOR SELF-INSURERS UNDER THE WORKERS' COMPENSATION ACT › Section 69L-5.106 - Financial Statement or Financial Summary (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					 440.38(2)(b),
					 440.591 FS. Law Implemented
					 440.38(1)(b)
					 FS.
New 10-1-82, Formerly 38F-5.47, Amended 6-12-91, 12-19-93,
					 5-14-96, Formerly 38F-5.047, Amended 5-19-97, Formerly 38F-5.106, 4L-5.106,
					 Amended 3-8-06, Repealed 3-9-10.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-5 - RULES FOR SELF-INSURERS UNDER THE WORKERS' COMPENSATION ACT › Section 69L-5.107 - Actuarial Reports (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					 440.38(1), (2)
					 FS. Law Implemented 440.38(1), (2)
					 FS.
New 5-19-97, Formerly 38F-5.107, 4L-5.107, Repealed
					 3-9-10.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-5 - RULES FOR SELF-INSURERS UNDER THE WORKERS' COMPENSATION ACT › Section 69L-5.108 - Security Deposits (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					 440.38(1)(b)
					 FS. Law Implemented 440.38(1)(b)
					 FS.
New 5-19-97, Formerly 38F-5.108, 4L-5.108, Repealed
					 3-9-10.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-5 - RULES FOR SELF-INSURERS UNDER THE WORKERS' COMPENSATION ACT › Section 69L-5.109 - Excess Insurance (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					 440.38(1)(b)
					 FS. Law Implemented 440.38(1)(b)
					 FS.
New 10-1-82, Formerly 38F-5.36, Amended 2-3-88, 12-19-93,
					 Formerly 38F-5.036, Amended 5-19-97, Formerly 38F-5.109, 4L-5.109, Repealed
					 3-9-10.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-5 - RULES FOR SELF-INSURERS UNDER THE WORKERS' COMPENSATION ACT › Section 69L-5.110 - Experience Records (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					 440.38(1)(b), (2)(b),
					 (3),
					 440.385 FS. Law Implemented
					 440.38(1)(b), (2)(b),
					 (3),
					 440.385
					 FS.
New 5-19-97, Formerly 38F-5.110, 4L-5.110, Repealed
					 3-9-10.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-5 - RULES FOR SELF-INSURERS UNDER THE WORKERS' COMPENSATION ACT › Section 69L-5.111 - Late Reports; Penalties (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					  440.38(1)(b),
					 (2)(b),
					  440.51 (6)(b),
					 440.5705 FS. Law Implemented
					 440.38(1)(b),
					 (2)(b),
					 440.51,
					  440.102,
					  624.24 FS.
New 10-1-82, Formerly 38F-5.38, Amended 12-19-93, Formerly
					 38F-5.038, Amended 5-19-97, Formerly 38F-5.111, 4L-5.111, Repealed
					 3-9-10.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-5 - RULES FOR SELF-INSURERS UNDER THE WORKERS' COMPENSATION ACT › Section 69L-5.112 - General Requirements (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					 440.38(1)(b), (2),
					 (4)(b),
					 440.49(1)(a),
					 440.56(4) FS.
					 Law Implemented  440.20(16),
					  440.38(1)(b),
					 (2),
					  440.49(1)(a),
					  440.56(4) 
					 FS.
New 10-1-82, Formerly 38F-5.31, Amended 12-19-93, Formerly
					 38F-5.031, Amended 5-19-97, Formerly 38F-5.112, 4L-5.112, Repealed
					 3-9-10.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-5 - RULES FOR SELF-INSURERS UNDER THE WORKERS' COMPENSATION ACT › Section 69L-5.113 - Application to Provide Servicing (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					  440.38(1)(b), (2),
					 (4)(b),
					  440.56(4)  FS.
					 Law Implemented 440.38(1)(b), (2),
					 (4)(b),
					 440.56(4)
					 FS.
New 10-1-82, Amended 12-25-84, Formerly 38F-5.40, Amended
					 12-19-93, Formerly 38F-5.040, Amended 5-19-97, Formerly 38F-5.113, 4L-5.113,
					 Repealed 3-9-10.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-5 - RULES FOR SELF-INSURERS UNDER THE WORKERS' COMPENSATION ACT › Section 69L-5.114 - Retaining Authorization as Service Company; Recertification (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					 440.591,
					 440.38(2)(a)
					 FS. Law Implemented 440.20(16),
					 440.38(1)(b), (2)(a), (b),
					 (4)(b)
					 FS.
New 10-1-82, Amended 12-25-84, Formerly 38F-5.41, Amended
					 6-12-91, 12-19-93, Formerly 38F-5.041, Amended 5-19-97, Formerly 38F-5.114,
					 4L-5.114, Repealed 3-9-10.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-5 - RULES FOR SELF-INSURERS UNDER THE WORKERS' COMPENSATION ACT › Section 69L-5.115 - Withdrawal of Authorization (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority 440.38(1)(b), (3)(b)5. FS. Law
					 Implemented 440.38(2), (3)
					 FS.
New 10-1-82, Formerly 38F-5.42, Amended 12-19-93, Formerly
					 38F-5.042, Amended 5-19-97, Formerly 38F-5.115, 4L-5.115, Repealed
					 3-9-10.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-5 - RULES FOR SELF-INSURERS UNDER THE WORKERS' COMPENSATION ACT › Section 69L-5.116 - Review and Audit (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					 440.38(2)(b),
					 440.51(6)(b)
					 FS. Law Implemented 440.20(16)(c),
					 440.38(1)(b),
					 (2)(b)
					 FS.
New 10-1-82, Formerly 38F-5.51, Amended 12-19-93, Formerly
					 38F-5.051, Amended 5-19-97, Formerly 38F-5.116, 4L-5.116, Repealed
					 3-9-10.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-5 - RULES FOR SELF-INSURERS UNDER THE WORKERS' COMPENSATION ACT › Section 69L-5.117 - Forms, Manuals, and Instructions (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority
					 440.57,
					 440.5705,
					 440.591 FS. Law Implemented
					 440.381,
					 440.57,
					 440.5705,
					 624.316,
					 624.424
					 FS.
New 5-19-97, Formerly 38F-5.117, 4L-5.117, Repealed
					 3-9-10.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-5 - RULES FOR SELF-INSURERS UNDER THE WORKERS' COMPENSATION ACT › Section 69L-5.202 - Scope of Self-Insurance Authorization

Current through Reg. 50, No. 138; July 16, 2024
(1) Approval of a self-insurance
				authorization in accordance with section
				 440.38, F.S., and these rules
				will be continuous unless and until revoked or voluntarily
				terminated.
(2) The self-insurance
				authorization of a Current Self-Insurer is restricted to the authorization
				holder and its wholly or majority owned subsidiaries.
(3) Where the Current Self-Insurer is an
				Affiliated Self-Insurer, the self-insurance authorization is restricted to
				entities affiliated by common majority ownership and their wholly or majority
				owned subsidiaries.
Rulemaking Authority
					  440.38(1), (2),
					 (3),
					 440.385(6),
					 440.591 FS. Law Implemented
					 440.38(1), (2),
					 (3),
					  440.385(1), (3),
					 (6) 
					 FS.
New 3-9-10.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-5 - RULES FOR SELF-INSURERS UNDER THE WORKERS' COMPENSATION ACT › Section 69L-5.203 - Payroll Reporting

Current through Reg. 50, No. 138; July 16, 2024
Self-Insurers shall report payroll data for all entities
				  covered under the self-insurance authorization using Form DFS-F2-SI-5
				  (Self-Insurer Payroll Report), effective 08/09, as incorporated by reference.
				  Failure to submit the required payroll reports, understatement or concealment
				  of payroll, or the misrepresentation of employee duties so as to avoid proper
				  classification shall constitute good cause for revocation of the self-insurance
				  authorization in addition to civil penalties specified in rule
				   69L-5.217, F.A.C. Copies of this
				  form are available at the Division of Workers' Compensation, Bureau of
				  Monitoring and Audit, Self-Insurance Section, 1579 Summit Lake Drive,
				  Tallahassee, FL 32317.
(1) Current
				Self-Insurers and Former Self-Insurers shall complete Form DFS-F2-SI-5
				(Self-Insurer Payroll Report), effective 08/09, by submitting payroll by
				classification code for the latest completed period beginning on the
				Anniversary Rating Date.
(2) Former
				Self-Insurers shall submit this report until the final payroll period has been
				reported.
(3) Current Self-Insurers
				shall submit Form DFS-F2-SI-5 (Self-Insurer Payroll Report), effective 08/09,
				no later than sixty (60) days after their Anniversary Rating Date. Former
				Self-Insurers shall submit their final Form DFS-F2-SI-5 (Self-Insurer Payroll
				Report), effective 08/09, no later than ninety (90) days after the revocation
				or voluntary termination of the self-insurance authorization.
(a) Governmental Entities and Public
				Utilities shall submit Form DFS-F2-SI-5 (Self-Insurer Payroll Report),
				effective 08/09, to the:
Department of Financial Services
Division of Workers' Compensation
Bureau of Monitoring and Audit/Self-Insurance
1579 Summit Lake Drive
Tallahassee, FL 32317
(b) FSIGA Members shall submit Form
				DFS-F2-SI-5 (Self-Insurer Payroll Report), effective 08/09, to the:
Florida Self-Insurers Guaranty Association, Inc.
1427 E. Piedmont Dr., 2nd Floor
Tallahassee, Florida
				  32308
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-5 - RULES FOR SELF-INSURERS UNDER THE WORKERS' COMPENSATION ACT › Section 69L-5.204 - Maintenance of Payroll Records, Review and Audit

Current through Reg. 50, No. 138; July 16, 2024
(1) The payroll records of all Current
				Self-Insurers and Former Self-Insurers shall be open for inspection and audit
				by the Department, or its Authorized Representative, during regular business
				hours. Self-insurers are required to maintain payroll records that reflect a
				true and accurate division by the classification codes contained in the SCOPES
				of Basic Manual Classifications and the NCCI Basic Manual for Workers'
				Compensation and Employers Liability Insurance so the proper classification
				code for each employee may be determined. The SCOPES of Basic Manual
				Classifications effective June 1, 2008 is hereby incorporated by reference. A
				copy of the SCOPES of Basic Manual Classifications may be obtained from the
				National Council on Compensation Insurance, Inc., Customer Service Center, 901
				Peninsula Corporate Circle, Boca Raton, FL 33487, telephone 1(800)622-4123. A
				copy of the manual is also available for viewing at the Division of Workers'
				Compensation, Bureau of Monitoring and Audit, Self-Insurance Section, 1579
				Summit Lake Drive, Tallahassee, FL 32317. The NCCI Basic Manual for Workers'
				Compensation and Employers Liability Insurance, 2001 Edition, including updates
				through June 1, 2009, is previously incorporated by reference into rule
				 69L-5.201, F.A.C. If such
				records are not maintained, then the entire payroll shall be presumed to be
				within the classification code to which the highest manual rate is applicable.
				To ensure their availability for audit purposes, the records shall be retained
				for five (5) years from the end of the payroll period. The location of these
				records shall be provided to the Department upon submission of the application
				for self-insurance and updated within fifteen (15) days of any
				relocation.
(2) At the conclusion
				of the audit conducted by the Department or its Authorized Representative, a
				preliminary report shall be prepared and sent to the self-insurer. The
				preliminary report shall identify any payroll or classification deficiencies.
				The self-insurer shall have thirty (30) days from the date of receipt to review
				and respond to the Department's preliminary report. The Department shall review
				the response and issue a final report.
Rulemaking Authority
					  440.38(1), (2),
					 (3),
					 440.385(6),
					 440.525(2),
					 440.591 FS. Law Implemented
					 440.38(1), (2),
					 (3),
					  440.385(1), (3),
					 (6),
					  440.525 FS.
New 3-9-10.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-5 - RULES FOR SELF-INSURERS UNDER THE WORKERS' COMPENSATION ACT › Section 69L-5.205 - Loss Data Reporting

Current through Reg. 50, No. 138; July 16, 2024
Current Self-Insurers and Former Self-Insurers shall submit
				  loss data for all entities covered under the self-insurance authorization on
				  Form DFS-F2-SI-17 (Unit Statistical Report), effective 08/09, as incorporated
				  by reference, or the electronic equivalent provided by the Department. Copies
				  of this form are available at the Division of Workers' Compensation, Bureau of
				  Monitoring and Audit, Self-Insurance Section, 1579 Summit Lake Drive,
				  Tallahassee, FL 32317. Failure to submit the required loss data forms or
				  material understatement or concealment of data shall constitute good cause for
				  revocation of the self-insurance authorization in addition to civil penalties
				  specified in Rule  69L-5.217, F.A.C.
(1) The Division or the Association shall,
				within at least ten (10) days prior to the evaluation date, notify in writing
				or email each self insurer of the covered periods for the submission of the
				loss data.
(2) Current
				Self-Insurers will complete Form DFS-F2-SI-17 (Unit Statistical Report),
				effective 08/09, or the electronic equivalent of Form DFS-F2-SI-17 (Unit
				Statistical Report), effective 08/09, by submitting loss data for the current
				evaluation year and the prior two (2) evaluation years.
(3) Former Self-Insurers shall continue to
				submit this report until the loss data for the final period of authorization
				has been reported.
(4) The
				completed Form DFS-F2-SI-17 (Unit Statistical Report), effective 08/09, or the
				electronic equivalent of Form DFS-F2-SI-17 (Unit Statistical Report), effective
				08/09, shall be mailed or transmitted to the Division or the Association no
				later than sixty (60) days after the evaluation date.
(a) Governmental Entities who are unable to
				transmit an electronic version of Form DFS-F2-SI-17 (Unit Statistical Report),
				effective 08/09, shall mail the completed Form DFS-F2-SI-17 (Unit Statistical
				Report), effective 08/09, no later than 60 days after the evaluation date to
				the:
Department of Financial Services
Division of Workers' Compensation
Bureau of Monitoring and Audit/Self-Insurance
1579 Summit Lake Drive
Tallahassee, FL 32317
(b) FSIGA Members who are unable to transmit
				the electronic version of Form DFS-F2-SI-17 (Unit Statistical Report),
				effective 08/09, shall mail the completed Form DFS-F2-SI-17 (Unit Statistical
				Report), effective 08/09, to:
Florida Self-Insurers Guaranty Association, Inc.
1427 E. Piedmont Dr., 2nd Floor
Tallahassee, Florida 32308