Mandatory Filing Requirements
Active Self-Insurers
As a Current Private Self-Insurer Employer, you are required to file important legible and complete documents to the Florida Self-Insurers Guaranty Association, Incorporated 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.
DFS-F2-SI-5
(Self-Insurer Payroll Report)
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)
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 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.
DFS-F2-SI-20 (Outstanding Workers’ Compensation Liabilities)
Within 90 days of the effective date of the policy. This is a onetime filing reported during your application process.
Where to send?
Florida Self-Insurers Guaranty Association, Incorporated, 1427 East Piedmont Drive, 2nd Floor, Tallahassee, Florida 32308.
How do I contact FSIGA?
Telephone Number: (850) 222-1882, Fax Number: (850) 222-2926 or visit their website at https://fsiga.org