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

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FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY
DIVISION OF WORKERS' COMPENSATION
BUREAU OF OPERATIONS SUPPORT
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 38F-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 38F-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 is has satisfied the servicing requirements as contained in Rule 38F-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 for 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 ______________________________________________________
LES Form SI-19 (09/96)

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