Forms for Governmental Self-Insured Employers
A Governmental Self-Insured Employer is required by law to provide important information to the Division annually. The Division has developed rules and adopted prescribed forms for self-insurers to use for reporting required information to the Division. A summary of relevant statutes, rules and forms are below. Please use the forms below for reporting required information to the Division.
Required Forms:
- DFS-F2-SI-1G Application for Governmental Self-Insurance (69L-5.223, F.A.C.)
- DFS-F2-SI-5 Self-Insurer Payroll Report (69L-5.203, F.A.C.)
- DFS-F2-SI-17 Unit Statistical Report (69L-5.205, F.A.C.)
- DFS-F2-SI-19 Certification of Servicing for Self-Insurers (69L-5.216(3), F.A.C.)
- DFS-F2-SI-GEP Application for Governmental Self-Insurance Estimated Payroll (69L-5.223, F.A.C.)
Premium Related Forms:
- DFS-F2-SI-8 Self-Insurance Employer Application for Drug-Free Work-Place Premium Credit Program (69L-5.220, F.A.C.)
- DFS-F2-SI-9 Self-Insurance Certification of Workplace Safety Program Premium Credit (69L-5.221, F.A.C.)