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

17. If a corporation, attach a list of the name and city and state of residence of each corporate officer; if a partnership,

the name and city and state of residence of each partner; if an individual proprietorship, the name and city and sta

of residence of the owner.

18. If a limited partnership, give the date of formation and duration of partnership.

19. Is the applicant a subsidiary?

If so, give the name and address of parent company:

20. In consideration of the approval of this application, the Applicant hereby expressly understands and agrees to the

following:

a. To maintain such security deposits and excess insurance as required by the rules of the Division.

b. To abide by all provision of Chapter 440, Florida Statutes, the Florida Workers’ Compensation Law and all

rules of the Division.

c. That the authorization to self-insure may be revoked for cause at the discretion of the Division as provided by

Section 440.38, Florida Statutes.

d. To fully discharge by cash payments all amounts required to be paid by the provisions of the Workers'

Compensation Law within the time periods prescribed by law.

e. To pay to the Division all assessments required by Chapter 440, Florida Statutes.

To pay to the Florida Self-Insurers Guaranty Association, Inc. all assessments required by Section 440.385,

Florida Statutes and Plan of Operation of the Florida Self-Insurers Guaranty Association, Inc.

g. That the self-insurance authorization extended upon approval of this application applies only to the Applicant

and such affiliates or subsidiaries in which it has a majority ownership interest and which are included on this

application.

h. That affiliates or subsidiaries in which the Applicant has majority ownership interest may be included under its

self-insurance authorization upon written notification to the Association.

That the self-insurance authorization extended upon approval of this application will not include any affiliates

or subsidiaries in which the applicant no longer has a majority ownership interest and such authorization will

expire and terminate without prior notice on the date that the Applicant relinquishes a majority ownership

interest.

That the self-insurance authorization extended upon approval of this application will be revoked by the

Division when the equity structure of the Applicant changes from that indicated by its application. That is, if

the Applicant is sold, merged, dissolved or otherwise changes its equity structure to the extent that the

financial information upon which the self-insurance authorization was granted can no longer be used to

determine the Applicant's financial strength.

, certify that all businesses included under this application are in

compliance with the coverage requirements of the workers' compensation law contained in Section 440.38(1), Florida

Statutes and that all such businesses will remain in compliance with this section pending approval of this application. I

further certify that all information contained in this application is true and correct to the best of my knowledge and that

the Applicant has not experienced a material adverse change in its financial condition since the date of the latest audited

financial statements.

Applicant _______________________________________

(Employer Name)

By:_________________________________________

(Signature)

Title:________________________________________

(Owner, Partner or Corporate Officer)

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

Page 3 of 3

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

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

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