RULE NO: RULE TITLE
69L-5.102: General Requirements

Notice is hereby given that the following changes have been made to the proposed rule in accordance with subparagraph 120.54(3)(d)1., F.S., published in Vol. 31 No. 49, December 9, 2005 issue of the Florida Administrative Weekly.

These changes are being made as a result of discussions and communications with the Joint Administrative Procedures Committee.

(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 90 days prior to the preferred effective date of self insured status, the following information: Employers within the scope of Section 440.38(6), Florida Statutes, shall be exempt from qualifying for self-insurance, but shall submit their intent to self-insure in writing to the division. These self-insurers shall not be required to submit an application, financial statement, security deposit, actuary report or proof of excess insurance. All other requirements established by these rules shall apply.

(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) Notification By Governmental Entity To Self-Insure For Workers’ Compensation, Form DFS-F2-SI-1G, incorporated by reference into rule (rev. 03/2006);

(c) Self-Insurance Estimated Payroll, Form DFS-F2-SI-EP, incorporated by reference into rule (rev. 03/2006);

(d) Certification of Servicing For Self-Insurers, Form SI-19, incorporated by reference into rule (rev. 09/1996); and

(e) Workers’ Compensation Experience Rating For Self-Insurers worksheet, Form ERM-6, for the current and two preceding years, as set forth in the National Council on Compensation Insurance (NCCI) Experience Rating Plan Manual for Workers’ Compensation and Employers Liability Insurance, incorporated by reference into rule (rev. 01/2002).

The notification and supporting documentation shall be submitted to the following address:

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 Chapter 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.

(3)(2) Change in numbering only.

(4)(3) Change in numbering only.

(5) Forms adopted. The forms set forth in paragraphs (1)(b)-(e), as well as the accompanying instructions to the forms, are hereby adopted. Copies of the forms set forth in paragraphs (1)(b)-(d) are available from the Division of Workers’ Compensation, Bureau of Monitoring and Audit, Self-insurance Section, 200 East Gaines Street, Tallahassee, FL 32399-4224. The form set forth in paragraph (1)(e) is found within the National Council on Compensation Insurance, Inc. (NCCI) Experience Rating Plan Manual for Workers’ Compensation and Employers Liability Insurance. A copy of the Manual and a one year subion to any and all updates may be obtained from the National Council on Compensation Insurance, Inc., 750 Commerce Drive, Boca Raton, FL 33487, telephone (800)622-4123, at a cost of $95. A copy of the Manual is also available for viewing at the Division of Workers’ Compensation, Bureau of Monitoring and Audit, Self-Insurance Section, 2012 Capital Circle, S.E., Hartman Building, Suite 200, Tallahassee, FL 32399-4224.

Specific Authority 440.38(2)(b), 440.591 FS. Law Implemented 440.38(6) FS. History–New 5-19-97, Formerly 38F-5.102, 4L-5.102, Amended ________.