Application Requirements

Private employers who want to self-insure for workers’ compensation purposes must meet the definition of Section 440.38(1)(b), F.S. Once your organization has determined that it meets the statutory definition it should proceed with completing the application form and all of the requirements outlined in rule. Below are the form, rules and statutes for employers requesting authorization to be approved as a private self-insurer.

Form:

• Application for Self-Insurance (DFS-F2-SI-1)

Rule:

• Application Process (69L-5.226, F.A.C.)

Florida Statute:

• Security for Compensation (440.38(1)(b) F.S.)

Required Documents ( Application Document Checklist )

• Section I - General
  • Completed Application for Self-Insurer, DFS-F2-SI-1
  • Application Financial Review Fee ($500)
  • Corporate Officer, Limited Partner or Individual Proprietor Listing
  • Subsidiary and Location Listing
  • Experience Modification Ratings
• Section II - Legal
  • Certificate of State from State of Domicile
  • Certificate of Status from Florida Secretary of State
  • Amendments to Articles of Incorporation for Successor Company(s)
  • Cross-Indemnity Agreement for Affiliated Self-Insurer
  • Parental Guaranty
• Section III - Financial
  • Annual Financial Statements
  • Interim Financial Statement
• Section IV - Servicing
  • Certification of Servicing for Self-Insurers (Form DFS-F2-SI-19)
  • Self Servicing

Mailing Address:

• Florida Self-Insurers Guaranty Association, Incorporated,
  1427 East Piedmont Drive, 2nd Floor,
  Tallahassee, Florida 32308.

Contact:

• Telephone Number: (850) 222-1882
• Website: https://fsiga.org