Form Si-19 - Certification Of Servicing For Self-Insurers printable pdf download

DIVISION OF WORKERS' COMPENSATION

BUREAU OF MONITORING AND AUDIT

SELF-INSURANCE SECTION

CERTIFICATION OF SERVICING FOR SELF-INSURERS

NAME OF SELF-INSURER

PART I

TO BE COMPLETED BY THE SERVICE COMPANY (IF APPLICABLE)

The undersigned service company certifies that the above self-insurer has satisfied the servicing

requirements as contained in Rule 4L-5.113, F.A.C., by contracting for the services indicated below on a full

time basis beginning on ________________________ and ending on ______________________.

INDICATE WITH AN "X": ¨ All (Claims Adjusting, Safety and Underwriting)

¨ Claims Adjusting

¨ Underwriting ¨ Safety

The undersigned service company also certifies that its contract with the above self-insurer complies with

Rule 4L-5.113, F.A.C.

Name of Service Company_______________________________________________________________

Signature ________________________________________ Date _______________________________

Name ____________________________________________ Title _______________________________

PART II

TO BE COMPLETED BY THE SELF-INSURER FOR SERVICES NOT

INCLUDED UNDER PART I

The undersigned self-insurer certifies that it has satisfied the servicing requirements as contained in Rule 4L-

5.113, F.A.C., by contracting with the firms listed below or by use of its own in-house personnel for the

indicated services.

INDICATE WITH AN "X":

¨ A. Claims:

¨ In-house

¨ Contracting with_______________________________________________

Beginning on __________________and ending on____________________

Note: Submit claims adjusting licenses for contract personnel and resumes or license numbers for in-house

personnel.

¨ B. Underwriting:

¨ In-house

¨ Contracting with_______________________________________________

Beginning on __________________and ending on______________

Note: Submit resumes of underwriting personnel.

¨ C. Safety

¨ In-house

¨ Contracting with________________________________________________

Beginning on ______________________and ending on_________________

Note: For in-house safety, submit a copy of your safety program or a letter of approval from the Division of

Safety.

PART III

TO BE COMPLETED BY THE SELF-INSURER

The undersigned self-insurer certifies that the information contained on and accompanying this form is true

and correct to the best of his/her knowledge.

Name of the Self-Insurer________________________________________________________________

Signature_____________________________________________ Date __________________________

Name_______________________________________________ Title____________________________

Form SI-19 (9/96)

Form Si-19 - Certification Of Servicing For Self-Insurers

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