Fla. Admin. Code Ann. R. 69L-5.207 - Outstanding Liabilities Reporting

Current through Reg. 47, No. 249; December 28, 2021

(1) Current Self-Insurers and Former Self-Insurers, other than Governmental Entities, shall report their outstanding self-insured workers' compensation liabilities for all entities covered under the self-insurance authorization on Form DFS-F2-SI-20 (Report of Outstanding Workers' Compensation Liabilities), effective 08/09, as incorporated by reference. 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. This includes all outstanding liabilities of Former Self-Insurers for which the Current Self-Insurer is the Successor Entity. Form DFS-F2-SI-20 (Report of Outstanding Workers' Compensation Liabilities), effective 08/09, shall be accompanied by a loss run substantiating all amounts reported on the form, be signed by an Authorized Representative of the Self-Insurer or its Qualified Servicing Entity, and be submitted no later than 120 days after the end of the self-insurer's fiscal year. 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. The evaluation date shall not be prior to the end of the self-insurer's latest fiscal year. Failure to submit the required Form DFS-F2-SI-20 (Report of Outstanding Workers' Compensation Liabilities), effective 08/09, or material understatement or concealment of loss reserves, 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.
(2) FSIGA Members shall submit Form DFS-F2-SI-20 (Report of Outstanding Workers' Compensation Liabilities), effective 08/09, to the:

Florida Self-Insurers Guaranty Association, Inc.

1427 E. Piedmont Dr., 2nd Floor

Tallahassee, Florida 32308

Notes

Fla. Admin. Code Ann. R. 69L-5.207
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.

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