69L-5.207. Outstanding Liabilities Reporting

(1) Current Self-Insurers and Former Self-Insurers, other than Governmental Entities, shall report their outstanding self-insured workers’ compensation liabilities for all entities covered under the self-insurance authorization on Form DFS-F2-SI-20 (Report of Outstanding Workers’ Compensation Liabilities), effective 08/09, as incorporated by reference. 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. This includes all outstanding liabilities of Former Self-Insurers for which the Current Self-Insurer is the Successor Entity. Form DFS-F2-SI-20 (Report of Outstanding Workers’ Compensation Liabilities), effective 08/09, shall be accompanied by a loss run substantiating all amounts reported on the form, be signed by an Authorized Representative of the Self-Insurer or its Qualified Servicing Entity, and be submitted no later than 120 days after the end of the self-insurer’s fiscal year. 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. The evaluation date shall not be prior to the end of the self-insurer’s latest fiscal year. Failure to submit the required Form DFS-F2-SI-20 (Report of Outstanding Workers’ Compensation Liabilities), effective 08/09, or material understatement or concealment of loss reserves, 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. (2) FSIGA Members shall submit Form DFS-F2-SI-20 (Report of Outstanding Workers’ Compensation Liabilities), effective 08/09, to the: Florida Self-Insurers Guaranty Association, Inc. 1427 E. Piedmont Dr., 2nd Floor Tallahassee, Florida 32308