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FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY

DIVISION OF WORKERS' COMPENSATION

BUREAU OF OPERATIONS SUPPORT

SELF-INSURANCE SECTION

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

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 38F-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 38F-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:

Corporation

Partnership

Individual proprietorship

Other ________________

(Check one)

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 ____________________________________________________________

LES Form SI-1a (Rev. 9/96)

Page 1 of 3

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

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