Application Requirements

Governmental employers who want to self-insure for workers’ compensation purposes must meet the definition of Section 440.38(6), F.S. Once your organization has determined that it meets the statutory definition, it should proceed with completing the government application form and all of the requirements outlined in governing rules. Please use the forms below when applying to become a governmental self-insured employer.

Rule:

• 69L-5.223, F.A.C., Election Process

Required Forms and/or Documents:

• DFS-F2-SI-1G, Application for Governmental Self-Insurance
• DFS-F2-SI-GEP, Application for Governmental Self-Insurance Estimated Payroll
• DFS-F2-SI-19, Certification of Servicing for Self-Insurers
• Copy of Articles of Incorporation, Charters or Bylaws through which the entity is organized or authorized
• Copies of NCCI Experience Modification Worksheets (current and two preceding years)

Mailing Address:

• Self-Insurance Unit
  Division of Workers’ Compensation
  Florida Department of Financial Services
  200 East Gaines Street
  Tallahassee, Florida 32399

Email:

• SelfInsurance.Unit@MyFloridaCFO.com

Contact Us:

• Dwayne Manning (850) 413-1784