69L-5.214. Indemnity Agreements for Affiliated Self-Insurers

Affiliated Self-Insurers must execute a new Form DFS-F2-SI-11 (Indemnity Agreement), effective 08/09, as incorporated by reference, within thirty (30) days of changes in the affiliates included under the self-insurance authorization. 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. Form DFS-F2-SI-11 (Indemnity Agreement), effective 08/09, shall be executed by an officer of each affiliated entity to be included under the self-insurance authorization. The executed form shall be submitted to the: Florida Self-Insurers Guaranty Association, Inc. 1427 E. Piedmont Dr., 2nd Floor Tallahassee, Florida 32308