Form Dfs-F2-Si-1 (8/2009) - Application For Self-Insurance (Page 2 of 3) in pdf

Form Dfs-F2-Si-1 (8/2009) - Application For Self-Insurance Page 2

6. Name of employee who will coordinate self-insurance program

6a. Title:

6b. Address if different from #3 above:

6c.Telephone number if different from #3a above:

7. Describe briefly the general nature of the operations performed in Florida or the items manufactured in Florida:

8. Applicant's primary North American Industry

Classification (NAIC) Code:

9. Describe briefly all work performed away from Florida locations:

10. Year business established:

If a corporation, under laws of what state?

11. Did you succeed anyone?

If so, whom?

12. Name of workers' compensation carrier at time of application:

13. What is the renewal date for your current workers' compensation coverage?

14. Attach a completed Certification of Servicing (Form DFS-F2-SI-19).

15. Attach a copy of at least your current experience modification rating, past two (2) if available.

16. Give the following estimated payroll information for your first twelve (12) months of self-insurance. Provide the

payroll classifications assigned to your operations using the classification system established by the National

Council on Compensation Insurance.

AMOUNT OF PAYROLL BY OCCUPATIONAL CLASSIFICATION

FOR DIVISION USE ONLY

Manual Annual

No. of

Payroll

Occupation

Payroll

Gross Premium

Rate

Employees

Class.

Total Premium $ _________________________

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

Page 2 of 3

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

Form Dfs-F2-Si-1 (8/2009) - Application For Self-Insurance Page 2