Current through Reg. 47, No. 249; December 28, 2021
Current Self-Insurers and Former Self-Insurers shall submit
loss data for all entities covered under the self-insurance authorization on
Form DFS-F2-SI-17 (Unit Statistical Report), effective 08/09, as incorporated
by reference, or the electronic equivalent provided by the Department. Copies
of this form are available at the Division of Workers' Compensation, Bureau of
Monitoring and Audit, Self-Insurance Section, 2012 Capital Circle, S.E.,
Hartman Building, Tallahassee, FL 32399-4224. Failure to submit the required
loss data forms or material understatement or concealment of data shall
constitute good cause for revocation of the self-insurance authorization in
addition to civil penalties specified in Rule
69L-5.217,
F.A.C.
(1) The Division or the
Association shall, within at least ten (10) days prior to the evaluation date,
notify in writing or email each self insurer of the covered periods for the
submission of the loss data.
(2)
Current Self-Insurers will complete Form DFS-F2-SI-17 (Unit Statistical
Report), effective 08/09, or the electronic equivalent of Form DFS-F2-SI-17
(Unit Statistical Report), effective 08/09, by submitting loss data for the
current evaluation year and the prior two (2) evaluation years.
(3) Former Self-Insurers shall continue to
submit this report until the loss data for the final period of authorization
has been reported.
(4) The
completed Form DFS-F2-SI-17 (Unit Statistical Report), effective 08/09, or the
electronic equivalent of Form DFS-F2-SI-17 (Unit Statistical Report), effective
08/09, shall be mailed or transmitted to the Division or the Association no
later than sixty (60) days after the evaluation date.
(a) Governmental Entities who are unable to
transmit an electronic version of Form DFS-F2-SI-17 (Unit Statistical Report),
effective 08/09, shall mail the completed Form DFS-F2-SI-17 (Unit Statistical
Report), effective 08/09, no later than 60 days after the evaluation date to
the:
Department of Financial Services
Division of Workers' Compensation
Bureau of Monitoring and Audit/Self-Insurance
200 East Gaines Street
Tallahassee, Florida 32399-4224
(b) FSIGA Members who are unable to transmit
the electronic version of Form DFS-F2-SI-17 (Unit Statistical Report),
effective 08/09, shall mail the completed Form DFS-F2-SI-17 (Unit Statistical
Report), effective 08/09, to:
Florida Self-Insurers Guaranty Association, Inc.
1427 E. Piedmont Dr., 2nd Floor
Tallahassee, Florida 32308
(5) The Division will promulgate the
experience modification using the NCCI Basic Manual for Workers' Compensation
and Employers' Liability Insurance and the NCCI Experience Rating Plan Manual
for Workers' Compensation and Employers' Liability Insurance. The NCCI
Experience Rating Plan Manual for Workers' Compensation and Employers Liability
Insurance, 2003 Edition, including updates through October 2008, and the NCCI
Basic Manual for Workers' Compensation and Employers Liability Insurance, 2001
Edition, including updates through June 1, 2009, are previously incorporated by
reference into Rule
69L-5.201,
F.A.C.
(6) The experience
modification shall be used in the calculation and collection of assessments for
the Workers' Compensation Administration Trust Fund, the Special Disability
Trust Fund, and the Florida Self-Insurers Guaranty Association, Inc.
(7) The Division shall provide a copy of the
experience rating worksheet to each self-insured employer and FSIGA.
Notes
Fla. Admin. Code Ann. R.
69L-5.205
Rulemaking Authority
440.38(1),
(2), (3),
440.385(6),
440.525(2),
440.591
FS. Law Implemented
440.38(1),
(2), (3),
440.385(1),
(3), (6),
440.525
FS.
New 3-9-10, Amended
12-29-11.
