69L-5.203. Payroll Reporting

Self-Insurers shall report payroll data for all entities covered under the self-insurance authorization using Form DFS-F2-SI-5 (Self-Insurer Payroll Report), effective 08/09, as incorporated by reference. Failure to submit the required payroll reports, understatement or concealment of payroll, or the misrepresentation of employee duties so as to avoid proper classification shall constitute good cause for revocation of the self-insurance authorization in addition to civil penalties specified in rule 69L-5.217, F.A.C. Copies of this form are available at the Division of Workers’ Compensation, Bureau of Monitoring and Audit, Self-Insurance Section, 1579 Summit Lake Drive, Tallahassee, FL 32317. (1) Current Self-Insurers and Former Self-Insurers shall complete Form DFS-F2-SI-5 (Self-Insurer Payroll Report), effective 08/09, by submitting payroll by classification code for the latest completed period beginning on the Anniversary Rating Date. (2) Former Self-Insurers shall submit this report until the final payroll period has been reported. (3) Current Self-Insurers shall submit Form DFS-F2-SI-5 (Self-Insurer Payroll Report), effective 08/09, no later than sixty (60) days after their Anniversary Rating Date. Former Self-Insurers shall submit their final Form DFS-F2-SI-5 (Self-Insurer Payroll Report), effective 08/09, no later than ninety (90) days after the revocation or voluntary termination of the self-insurance authorization. (a) Governmental Entities and Public Utilities shall submit Form DFS-F2-SI-5 (Self-Insurer Payroll Report), effective 08/09, to the: Department of Financial Services Division of Workers’ Compensation Bureau of Monitoring and Audit/Self-Insurance 1579 Summit Lake Drive Tallahassee, FL 32317 (b) FSIGA Members shall submit Form DFS-F2-SI-5 (Self-Insurer Payroll Report), effective 08/09, to the: Florida Self-Insurers Guaranty Association, Inc. 1427 E. Piedmont Dr., 2nd Floor Tallahassee, Florida 32308