69H-2.004. Certificate of Coverage

(1) The Department shall adopt and use a Certificate of Coverage form indicating the insured agency and the coverage provided by the Fund. (2) Form Dfs-d0-867, “State Employee Workers’ Compensation and Employer’s Liability Certificate of Coverage,” (Effective 07/23), incorporated herein by reference, will be used to provide employee workers’ compensation and employer’s liability coverage to the agency named on the certificate. A copy of the form is available at http://www.flrules.org/Gateway/reference.asp?No=Ref-15485. (3) Form Dfs-d0-863, “General Liability Certificate of Coverage,” (Effective 07/23), incorporated herein by reference, will be used to provide general liability insurance coverage to the agency named on the certificate. A copy of the form is available at http://www.flrules.org/Gateway/reference.asp?No=Ref-15482. (4) Form DFS-D0-864, “Automobile Liability Certificate of Coverage,” (Effective 07/23), incorporated herein by reference, will be used to provide fleet automobile liability coverage to the agency named on the certificate. A copy of the form is available at http://www.flrules.org/Gateway/reference.asp?No=Ref-15483. (5) Form DFS-D0-864A, “State Risk Management Trust Fund Addendum to Automobile Liability Certificate of Coverage for Off-Duty Law Enforcement Vehicle Property Damage,” (Rev. 11/05), incorporated herein by reference, will be used to provide an addendum to automobile liability coverage to the agency named on the certificate. (6) Form Dfs-d0-865, “Federal Civil Rights Liability and Employment Discrimination Certificate of Coverage,” (Effective 07/23), incorporated herein by reference, will be used to provide coverage for federal civil rights actions under 42 U.S.C. 1983 or similar federal statutes to the agency named on the certificate. A copy of the form is available at http://www.flrules.org/Gateway/reference.asp?No=Ref-15494. (7) Form DFS-D0-862, “Court Awarded Attorney Fees Certificate of Coverage,” (Rev. 11/05), incorporated herein by reference, will be used to provide coverage for court awarded attorney’s fees in other proceedings against the agency named on the certificate. (8) Form DFS-D0-1994, Firefighter Cancer Benefits Certificate of Coverage, (Effective 07/23), incorporated herein by reference, will be used to provide coverage for firefighter cancer benefits payable under Section 112.1816(2), F.S. A copy of the form is available at http://www.flrules.org/Gateway/reference.asp?No=Ref-15492. (9) Copies of these forms are available from the Division of Risk Management, Department of Financial Services, 200 East Gaines Street, Tallahassee, FL 32399-0337, or at https://myfloridacfo.com/Division/Risk/.