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DIVISION OF WORKERS' COMPENSATION

BUREAU OF MONITORING AND AUDIT

SELF-INSURANCE SECTION

RE-APPLICATION FOR SELF-INSURANCE BY PREVIOUSLY SELF-INSURED ENTITY WHICH RESTRUCTERED

INSTRUCTIONS

All information entered on this application must be typewritten and the application and all accompanying

documents must be filed in duplicate to: Self-Insurance Section, P.O. Box 5497, Tallahassee, Florida 32314-5497.

All financial information submitted with this application must be prepared in accordance with United States

Generally Accepted Accounting Principles. Three years of audited financial statements or pro forma financial

statements, reviewed by an independent Certified Public Accountant in accordance with Statement on

Standards for Accountants Services on Prospective Financial Information, Financial Forecast and Projections,

must accompany this application. All financial information submitted with this application must be in the

name entered on Line 1 below.

The undersigned employer (hereinafter referred to as the applicant), an employer subject to the provisions of

the Florida Workers' Compensation Law, hereby makes application for the status of a self-insurer in order to pay

compensation directly. In connection with such application, the applicant makes the following declarations

for the purpose of enabling the Division of Workers' Compensation (hereinafter referred to as the Division) to

make a finding of facts as to whether the applicant meets the qualifications for self-insurance established in

Rule Chapter 4L-5, Florida Administrative Code.

The division will review this application and accompanying documents and will advise the applicant in writing

of any additional requirements imposed by Rule Chapter 4L-5. All requirements shall be fulfilled prior to the

division's approval of this application. The approval or denial of this application is governed by Sections 120.57

and 120.60, Florida Statutes and the applicable rules of procedure. In the event this application is denied, the

applicant shall have the right to request an administrative hearing on the denial of the application in

accordance with Sections 120.57 and 120.60, Florida Statutes. If all requirements to self-insure are not met

within 30 days of the date of application, the division reserves the right to deny this application without

prejudice.

1. Name of Applicant

2. Applicant's Federal Employer Identification Number

3. Address - Principal Office

3a.

Telephone number

4. Attach a list of all subsidiary or affiliated companies which are to be included under the applicant's self-

insurance privilege.

Indicate the percentage ownership of the applicant in each subsidiary or affiliated

company. Include the

address of each Florida location for each subsidiary or affiliated company.

5. Applicant is a (check one): corporation

, partnership

, individual proprietorship

or other ______________

Attach proof that applicant or subsidiaries are registered Florida corporations.

6. Name of employee who will coordinate self-insurance program

6a.

Title:

6b.

Address if different from #3 above

6c.

Telephone number if different from #3a above

Form SI-1a

Page 1 of 3

Form Si-1a - Re-Application For Self-Insurance By Previously Self-Insured Entity Which Restructered

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