Mandatory Filing Requirements for Active Self-Insurers
As an active Governmental Self-Insurer Employer, you are required to file important legible and complete documents to the Division timely to avoid being assessed civil penalties up to $5,000 outlined in Rule 69L-5.217, F.A.C. Please use the information outlined below as a helpful guideline to ensure the proper filing of these forms, reports or documents.
Form
When to File
Rule
DFS-F2-SI-5 
(Self-Insurer Payroll Report)
60 days after the Rating Effective Date (RED).
What is a Rating Effective Date (RED)? A Rating Effective Date (RED) is the effective month and day of the beginning of the self-insurance authorization and each anniversary thereafter unless a different date is established (69L-5.201, F.A.C.)
What is a Rating Effective Date (RED)? A Rating Effective Date (RED) is the effective month and day of the beginning of the self-insurance authorization and each anniversary thereafter unless a different date is established (69L-5.201, F.A.C.)
DFS-F2-SI-17 (Unit
Statistical Report)
No later than 60 days after the evaluation date.
What is an evaluation date? An evaluation date is 6 months after the Rating Effective Date
What is an evaluation date? An evaluation date is 6 months after the Rating Effective Date
DFS-F2-SI-19 (Certification of Servicing for Self-Insurers)
If a change in Servicing of Claims, this form must be filed within 30 days of that change.
If contracting with a Qualified Servicing Entity (QSE), this form must be filed within 30 days of entering into a servicing contract agreement.
If contracting with a Qualified Servicing Entity (QSE), this form must be filed within 30 days of entering into a servicing contract agreement.
- If the expiring contract is renewed with the same QSE, this form must be filed 30 days after the expiration date of the contract being renewed.
- If the contract is continuous or is greater than 3 years, this form must be filed no later than 3 years and 30 days from the date of submission of the prior SI-19.
Where to send?
Department of Financial Services
Division of Workers’ Compensation
Self-Insurance Section
200 East Gaines Street
Tallahassee, Florida 32399