Qualified Servicing Entity (QSE) Forms

The forms below are related to the QSE application process, the QSE annual recertification process, and the claims data reporting process. These forms should be utilized by entities applying to become a QSE, active QSEs that are required to submit annual reports and QSE’s submitting information on behalf of carriers. To view these forms you can click on the links below:

Applications & Annual Recertifications

• DFS-F2-SI-22, Qualified Servicing Entity Application
• DFS-F2-SI-23, Qualified Servicing Entity Annual Report
• DFS-F2-SI-27, Biographical Statement and Affidavit

Other Forms

• DFS-F2-SI-17, Unit Statistical Report
• DFS-F2-SI-19, Certification of Servicing for Self-Insurers
• DFS-F2-SI-20, Report of Outstanding Workers’ Compensation Liabilities