Form Dfs-F2-Si-17 (8/2009) - Unit Statistical Report
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4FLORIDA DEPARTMENT OF FINANCIAL SERVICES
REPORT DUE DATE
DIVISION OF WORKERS' COMPENSATION
BUREAU OF MONITORING AND AUDIT
SELF-INSURANCE SECTION
Page
of
Pages
UNIT STATISTICAL REPORT
REPORT NUMBER
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FEIN NUMBER
CARRIER NUMBER
SELF-INSURER’S NAME AND ADDRESS
999-
BEGINNING DATE
ENDING DATE
ACCOUNT NUMBER
EVALUATION DATE
IF ANY OF THE INFORMATION ENTERED ON THE
FORM IS ILLEGIBLE OR NOT IN COMPLIANCE WITH
THE INSTRUCTIONS, THE FORM WILL BE RETURNED UNPROCESSED.
SOCIAL SECURITY
STATUS
INJURY
PAYROLL
DATE OF
INCURRED LOSS
NO. OR NUMBER
CODE
CLASS
ACCIDENT
MEDICAL
INDEMNITY
(EXCESS CLAIMS ONLY)
OF CLAIMS
CODE*
TOTALS $ ___________
$___________
ENTER TOTAL ALLOCATED
LOSS ADJUSTMENT EXPENSE INCURRED
*Only payroll classification codes shown on the self-insurer payroll
.
report for the corresponding payroll period can be used on this form
REPORT COMPLETED BY:
___________________________________________________
___________________________________________________
(Print Name & Title):
(Signature)
___________________________________________________
___________________________________________________
(Company)
(Address)
___________________________________________________
___________________________________________________
(Telephone)
(City, State, Zip)
PLEASE RETURN COMPLETED REPORT TO:
FSIGA MEMBERS
GOVERNMENTALS
Florida Self-Insurers Guaranty Association Inc.
Division of Workers’ Compensation
1427 East Piedmont Drive, 2nd Floor
Bureau of Monitoring & Audit, Self-Insurance Section
Tallahassee, Florida 32308
200 East Gaines Street
(850) 222-1882
Tallahassee, Florida 32399-4224
FORM DFS-F2-SI-17 (8/2009)
Rule 69L- 5.205, F.A.C
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