Form Dfs-F2-Si-1 (8/2009) - Application For Self-Insurance printable pdf download

FLORIDA DEPARTMENT OF FINANCIAL SERVICES

DIVISION OF WORKERS' COMPENSATION

BUREAU OF MONITORING AND AUDIT

SELF-INSURANCE SECTION

APPLICATION FOR SELF-INSURANCE

INSTRUCTIONS

All information entered on this application must be typewritten. The application and all accompanying documents must be

filed in duplicate to: Florida Self-Insurers Guaranty Association, Inc., 1427 East Piedmont Drive., 2

Floor, Tallahassee,

Florida 32308, (hereinafter referred to as the Association.) All financial information submitted with this application must

be prepared in accordance with United States Generally Accepted Accounting Principles. The current fiscal year-end

financial statements as well as the prior fiscal year-end statements must accompany this application. If the financial

statements are not on a comparative basis with the prior year, then the three most recent statements must be submitted.

The most recent year financial statements must be audited in accordance with Generally Accepted Auditing Standards. If

financial statements for the two prior years have been audited in accordance with Generally Accepted Auditing Standards,

then those audited financial statements must be submitted as well. If the date of the latest audited financial statements is

over six months old at the time of application, interim financial statements up to and including at least the latest fiscal

quarter must be included and must be certified as to their accuracy by a corporate officer, general partner, or sole

proprietor. 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 69L-5, Florida Administrative Code.

The Association will review this application and accompanying documents and will advise the Applicant in writing of any

additional requirements imposed by Rule 69L-5, Florida Administrative Code. 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 90 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.

Form DFS-F2-SI-1 (8/2009)

Page 1 of 3

Rule 69L-5.226, F.A.C.

Form Dfs-F2-Si-1 (8/2009) - Application For Self-Insurance

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