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-5.226 - Application Process

Current through Reg. 50, No. 138; July 16, 2024
(1) An application
				for self-insurance shall be made on Form DFS-F2-SI-1 (Application for
				Self-Insurance), effective 08/09, as incorporated by reference. An application
				may be obtained at:
Florida Self-Insurers Guaranty Association, Inc.
1427 E. Piedmont Dr., 2nd Floor
Tallahassee, FL 32308
or
www.fsiga.org
(2) All applications for self-insurance shall
				be submitted in duplicate at least ninety (90) days prior to the desired
				effective date. Self-insurance effective dates shall be determined by the
				Department with consideration given to the date selected by the applicant and
				shall always be on the first of the month. However, on no occasion shall the
				effective date be more than six (6) months after the approval date.
(3) The following information shall be
				submitted in duplicate with the application:
(a) The most recent three (3) years of
				Financial Statements that conform to the requirements of Rule
				 69L-5.225, F.A.C.
(b) If the date of the latest Financial
				Statements is over six (6) months old at the time of application, interim
				financial statements, up to and including at least the latest fiscal quarter,
				must be included and must be certified as to their accuracy by a corporate
				officer, general partner or sole proprietor.
(c) A completed Form DFS-F2-SI-19
				(Certification of Servicing for Self-Insurers), effective 08/09, as previously
				incorporated by reference in Rule
				 69L-5.216, F.A.C., detailing the
				proposed servicing arrangements and accompanying documentation that conforms to
				the requirements of Rule
				 69L-5.216, F.A.C.
(d) A list of all entities which the
				applicant intends to include under its self-insurance authorization in
				accordance with Rule  69L-5.202, F.A.C., that includes
				the following information:
1. Percentage of
				the applicant's ownership interest in each entity;
2. Federal Employer Identification Number
				(FEIN) of each entity;
3. Addresses
				of each entity and its operating locations within the State of Florida;
				and,
4. Any fictitious names used
				by each entity within the State of Florida.
(e) If the applicant is seeking approval as
				an Affiliated Self-Insurer, Form DFS-F2-SI-11 (Indemnity Agreement), effective
				08/09, as previously incorporated by reference in Rule
				 69L-5.214, F.A.C., shall be
				executed by an officer of each affiliated company to be included under the
				self-insurance authorization.
(f)
				If the applicant is seeking approval using the Financial Statements of a parent
				company under Rule  69L-5.215, F.A.C., Form
				DFS-F2-S1-10 (Parental Guaranty and Corporate Resolution for Self-Insured
				Subsidiary Entity), effective 08/09, as previously incorporated by reference in
				Rule  69L-5.215, F.A.C., must be
				executed by a corporate officer of the parent company.
(g) A list of corporate officers, general
				partners, or sole proprietor as applicable to the corporate structure of the
				applicant including the resident city and state and the full business address
				of each.
(h) Certification by a
				corporate officer, general partner, or sole proprietor stating that the
				applicant, at the time of application, and until approval of the application,
				will maintain workers' compensation insurance coverage in compliance with
				Section  440.38(1)(a),
				F.S.
(i) Certification by a
				corporate officer, general partner, or sole proprietor stating that the
				applicant has not experienced a material adverse change in its financial
				condition since the date of the latest provided Financial Statements.
(j) A certificate of status from the
				applicant's state of domicile, along with a certificate of status from the
				State of Florida, issued within the last six (6) months.
(k) If the name of the entity has changed in
				the last three (3) years, documentation of the change as filed with the
				applicant's state of domicile.
(l)
				Experience modification promulgation worksheet for the current and two (2)
				preceding years as set forth in the NCCI Experience Rating Plan Manual for
				Workers' Compensation and Employers Liability Insurance as previously
				incorporated by reference in Rule
				 69L-5.201, F.A.C.
(m) A Security Deposit that conforms to the
				requirements of Rule  69L-5.218, F.A.C.
(n) Proof of a Specific Excess Insurance
				Policy that conforms to Rule
				 69L-5.219,
				F.A.C.