Fla. Admin. Code Ann. R. 69L-5.226 - Application Process
Current through Reg. 47, No. 249; December 28, 2021
(1) An application
for self-insurance shall be made on Form DFS-F2-SI-1 (Application for
Self-Insurance), effective 08/09, as incorporated by reference. An application
may be obtained at:
Florida Self-Insurers Guaranty Association, Inc.
1427 E. Piedmont Dr., 2nd Floor
Tallahassee, FL 32308
or:
www.fsiga.org
(2) All applications for self-insurance shall
be submitted in duplicate at least ninety (90) days prior to the desired
effective date. Self-insurance effective dates shall be determined by the
Department with consideration given to the date selected by the applicant and
shall always be on the first of the month. However, on no occasion shall the
effective date be more than six (6) months after the approval date.
(3) The following information shall be
submitted in duplicate with the application:
(a) The most recent three (3) years of
Financial Statements that conform to the requirements of Rule
69L-5.225,
F.A.C.
(b) If the date of the
latest Financial Statements is over six (6) months old at the time of
application, interim financial statements, up to and including at least the
latest fiscal quarter, must be included and must be certified as to their
accuracy by a corporate officer, general partner or sole proprietor.
(c) A completed Form DFS-F2-SI-19
(Certification of Servicing for Self-Insurers), effective 08/09, as previously
incorporated by reference in Rule 5.216, F.A.C., detailing the proposed
servicing arrangements and accompanying documentation that conforms to the
requirements of Rule
69L-5.216,
F.A.C.
(d) A list of all entities
which the applicant intends to include under its self-insurance authorization
in accordance with Rule
69L-5.202,
F.A.C., that includes the following information:
1. Percentage of the applicant's ownership
interest in each entity,
2. Federal
Employer Identification Number (FEIN) of each entity,
3. Addresses of each entity and its operating
locations within the State of Florida, and
4. Any fictitious names used by each entity
within the State of Florida.
(e) If the applicant is seeking approval as
an Affiliated Self-Insurer, Form DFS-F2-SI-11 (Indemnity Agreement), effective
08/09, as previously incorporated by reference in Rule
69L-5.214,
F.A.C., shall be executed by an officer of each affiliated company to be
included under the self-insurance authorization.
(f) If the applicant is seeking approval
using the Financial Statements of a parent company under Rule
69L-5.215,
F.A.C., Form DFS-F2-S1-10 (Parental Guaranty and Corporate Resolution for
Self-Insured Subsidiary Entity), effective 08/09, as previously incorporated by
reference in Rule
69L-5.215,
F.A.C., must be executed by a corporate officer of the parent
company.
(g) A list of corporate
officers, general partners, or sole proprietor as applicable to the corporate
structure of the applicant including the resident city and state and the full
business address of each.
(h)
Certification by a corporate officer, general partner, or sole proprietor
stating that the applicant, at the time of application, and until approval of
the application, will maintain workers' compensation insurance coverage in
compliance with Section
440.38(1)(a),
F.S.
(i) Certification by a
corporate officer, general partner, or sole proprietor stating that the
applicant has not experienced a material adverse change in its financial
condition since the date of the latest provided Financial Statements.
(j) A certificate of status from the
applicant's state of domicile, along with a certificate of status from the
State of Florida, issued within the last six (6) months.
(k) If the name of the entity has changed in
the last three (3) years, documentation of the change as filed with the
applicant's state of domicile.
(l)
Experience modification promulgation worksheet for the current and two (2)
preceding years as set forth in the NCCI Experience Rating Plan Manual for
Workers' Compensation and Employers Liability Insurance as previously
incorporated by reference in Rule
69L-5.201,
F.A.C.
(m) A Security Deposit that
conforms to the requirements of Rule
69L-5.218,
F.A.C.
(n) Proof of a Specific
Excess Insurance Policy that conforms to Rule
69L-5.219,
F.A.C.
(4) Upon
receiving the application, the Association shall review the application. Any
additional information needed to complete the application shall be requested
within thirty (30) days.
(5) The
application is not complete for purposes of Section
120.60, F.S., until all
of the above requirements are met and the required documents are submitted to
the Association. The Department shall not approve any application for
self-insurance until the application is complete including the submission of
the Security Deposit, proof of Specific Excess Insurance Policy and
Certification of Servicing for Self-Insurers.
Notes
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