Les Form Si-23 - Service Company Annual Report Form printable pdf download

Les Form Si-23 - Service Company Annual Report Form

FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY

DIVISION OF WORKERS' COMPENSATION

BUREAU OF OPERATIONS SUPPORT

SELF-INSURANCE SECTION

SERVICE COMPANY ANNUAL REPORT FORM

1. Name of business

2. Address of home office

3. Please note if your home office is not the location of your records, indicate the address of such records.

Please complete the following items only if there has been a change from that reported on your application or on your

last annual report. If there has been no change, please write "No Change". Attach additional sheets if necessary.

4. Address of your Florida branch offices

5. Your business is a:

Corporation

Partnership

Other _______________________

Individual Proprietorship

6. Name and addresses of owners, partners or corporate officers

7. Is your business a subsidiary? If yes, give the name and address of your

parent company:

Yes

For items 8 and 9, please note any changes from your last annual report or from your original application. Please

include residences and business addresses for all new personnel submitting a resume. If your answer is "yes" to any of

these questions, attach summary data on the size and composition of the appropriate staff; include resumes on any new

individuals with administrative or professional responsibilities.

8. Have there been any changes in your claims staff?

Yes

9. Have there been any changes in your underwriting staff?

Yes

10. Have there been any changes in your safety engineering staff?

Yes

11. If you have made substantial changes in your safety program, have they

been approved by the Division of Workers' Compensation?

Yes

12. Do you wish to name a new person to act for your business in Florida? If

yes, list the name, address and telephone number of that person:

Yes

LES Form SI-23 (09/96)

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Les Form Si-23 - Service Company Annual Report Form