Fla. Admin. Code Ann. R. 69L-5.223 - Election Process

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

(1) The state and its boards, bureaus, departments, and agencies and all of its political subdivisions which employ labor, and the state universities that are electing to self-insure pursuant to Section 440.38(6), F.S., shall submit to the Division for review at least ninety (90) days prior to the preferred effective date of self-insured status, the following information:
(a) Copy of document(s) through which the entity is organized or authorized to operate as a Governmental Entity, including articles of incorporation, grant of authority, or charter, if applicable;
(b) Application for Governmental Self-Insurance, Form DFS-F2-SI-1G, effective 08/09, as incorporated by reference;
(c) Application for Governmental Self-Insurance Estimated Payroll, Form DFS-F2-SI-GEP, effective 08/09, as incorporated by reference;
(d) Certification of Servicing for Self-Insurers, Form DFS-F2-SI-19, effective 08/09, as previously incorporated by reference in Rule 69L-5.216, F.A.C.; and
(e) NCCI Workers' Compensation Experience Modification Promulgation Worksheet for the current and two (2) preceding years, as set forth in the National Council on Compensation Insurance (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, is previously incorporated by reference into Rule 69L-5.201, F.A.C.

The notification, forms and supporting documentation can be obtained from and shall be submitted 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

(2) Upon receipt of the notification and supporting documentation from an entity defined within the scope of Section 440.38(6), F.S., the Division shall provide to the entity the "Insurer Code #" pursuant to Rule 69L-3.002, F.A.C., prior to the effective date of self-insured status for compliance with filing requirements of Rule Chapters 69L-3 and 69L-7, F.A.C.


Fla. Admin. Code Ann. R. 69L-5.223
Rulemaking Authority 440.38(1), (2), (3), 440.385(6), 440.591 FS. Law Implemented 440.38(1), (2), (3), 440.385(1), (3), (6) FS.
New 3-9-10.

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