Section 69L-5.226 - Application Process(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 69L-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.Fla. Admin. Code Ann. R. 69L-5.226
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.