Fla. Admin. Code Ann. R. 69L-5.214 - Indemnity Agreements for Affiliated Self-Insurers
Current through Reg. 47, No. 249; December 28, 2021
Affiliated Self-Insurers must execute a new Form DFS-F2-SI-11 (Indemnity Agreement), effective 08/09, as incorporated by reference, within thirty (30) days of changes in the affiliates included under the self-insurance authorization. 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. Form DFS-F2-SI-11 (Indemnity Agreement), effective 08/09, shall be executed by an officer of each affiliated entity to be included under the self-insurance authorization. The executed form shall be submitted to the:
Florida Self-Insurers Guaranty Association, Inc.
1427 E. Piedmont Dr., 2nd Floor
Tallahassee, Florida 32308
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