Forms for Private Self-Insured Employers
A Private 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. A summary of relevant statutes, rules and forms are referenced below.
Forms:
| List of Forms for Private Self-Insured Employers | ||
| Filing Form | How to Submit the Form | Contact for Submission |
| DFS-F2-SI-1, Application for Self-Insurance | Mail to FSIGA | Florida Self-Insurers Guaranty Association Inc. 1427 East Piedmont Drive, 2nd Floor Tallahassee, Florida 32308 (850) 222-1882 www.fsiga.org |
| DFS-F2-SI-4F, Self-Insurer’s Surety Bond for FSIGA Members | Mail to FSIGA | Florida Self-Insurers Guaranty Association Inc. 1427 East Piedmont Drive, 2nd Floor Tallahassee, Florida 32308 (850) 222-1882 www.fsiga.org |
| DFS-F2-SI-5, Self-Insurer Payroll Report | Link to guide | START |
| DFS-F2-SI-6, Self-Insurer’s Irrevocable Letter of Credit | Mail to FSIGA | Florida Self-Insurers Guaranty Association Inc. 1427 East Piedmont Drive, 2nd Floor Tallahassee, Florida 32308 (850) 222-1882 www.fsiga.org |
| DFS-F2-SI-8, Self-Insurance Employer Application for Drug-Free Work-Place Premium Credit Program | Mail to AU | Florida Division of Workers’ Compensation Bureau of Financial Accountability’s Assessments Unit 200 E. Gaines Street Tallahassee, FL 32399-4221 assessments.unit@myfloridacfo.com |
| DFS-F2-SI-9 Self-Insurance Certification of Workplace Safety Program Premium Credit | Mail to AU | Florida Division of Workers’ Compensation Bureau of Financial Accountability’s Assessments Unit 200 E. Gaines Street Tallahassee, FL 32399-4221 assessments.unit@myfloridacfo.com |
| DFS-F2-SI-10, Parental Guaranty and Corporate Resolution | Mail to FSIGA | Florida Self-Insurers Guaranty Association Inc. 1427 East Piedmont Drive, 2nd Floor Tallahassee, Florida 32308 (850) 222-1882 www.fsiga.org |
| DFS-F2-SI-11, Indemnity Agreement | Mail to FSIGA | Florida Self-Insurers Guaranty Association Inc. 1427 East Piedmont Drive, 2nd Floor Tallahassee, Florida 32308 (850) 222-1882 www.fsiga.org |
| DFS-F2-SI-17 Unit Statistical Report (69L-5.205, F.A.C.) | Link to guide SI-17 Reporting Training Manual - Excel File SI-17 Reporting Training Manual - Text File | START |
| DFS-F2-SI-19 Certification of Servicing for Self-Insurers (69L-216, F.A.C.) | Go to the Claims section of the START Portal | START |
| DFS-F2-SI-20 Report of Outstanding Workers’ Compensation Liabilities (69L-207, F.A.C.) | Mail to FSIGA | Florida Self-Insurers Guaranty Association Inc. 1427 East Piedmont Drive, 2nd Floor Tallahassee, Florida 32308 (850) 222-1882 www.fsiga.org |