Mandatory Filing Requirements for Former Self-Insurers

Former Self-Insurers

As a Former 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)	90 days after the cancellation date and must be submitted until the final payroll period has been reported.	69L-5.203, F.A.C.
DFS-F2-SI-17 (Unit Statistical Report)	No later than 60 days after the cancelation date and must be submitted until the loss data for the final period of authorization has been reported.	69L-5.205, F.A.C.
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 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.	69L-5.216, F.A.C.

Where to send?

Department of Financial Services
Division of Workers' Compensation
Self-Insurance Section
200 East Gaines Street
Tallahassee, Florida 32399