Mandatory Filing Requirements
Private Self-Insured Employers are required to file important information on an annual basis with the Division of Workers’ Compensation. A self-insurer is responsible for being aware of these obligations and their corresponding due dates. Florida statutes and rules specify the required information that must be filed, the form it must be provided on, and when the form is due. Self-insurers that do not file their information timely are subject to penalties (69L-5.217, F.A.C.). Please use the forms below for reporting required information to the Florida Self-Insurers Guaranty Association, Incorporated.
Mandatory Filing Requirements Checklists
Active Private Self-Insured Employers (Checklist)
- 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-216, F.A.C.)
- DFS-F2-SI-20 Report of Outstanding Workers’ Compensation Liabilities (69L-207, F.A.C.)
- Specific Excess Insurance Policy (69L-5.207, F.A.C.)
- Financial Statement (69L-5.209, F.A.C.)
- Actuarial Report (as determined by FSIGA and the Division) (69L-5.210, F.A.C.)
Former (Terminated) Private Self-Insured Employers with Open Claims (Checklist)
- DFS-F2-SI-19 Certification of Servicing for Self-Insurers (69L-216, F.A.C.)
- DFS-F2-SI-20 Report of Outstanding Workers’ Compensation Liabilities (69L-207, F.A.C.)
- Financial Statement (69L-5.209, F.A.C.)
- Actuarial Report (as determined by FSIGA and the Division) (69L-5.210, F.A.C.)
Mailing Address:
- Florida Self-Insurers Guaranty Association, Incorporated
427 East Piedmont Drive, 2nd Floor
Tallahassee, Florida 32308
Contact FSIGA:
- Telephone Number: (850) 222-1882 or visit their website at https://fsiga.org