FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION BUREAU OF MONITORING AND AUDIT SELF-INSURANCE SECTION APPLICATION FOR SELF-INSURANCE INSTRUCTIONS All information entered on this application must be typewritten. The application and all accompanying documents must be filed in duplicate to: Florida Self-Insurers Guaranty Association, Inc., 1427 East Piedmont Drive., 2nd Floor, Tallahassee, Florida 32308, (hereinafter referred to as the Association.) All financial information submitted with this application must be prepared in accordance with United States Generally Accepted Accounting Principles. The current fiscal year-end financial statements as well as the prior fiscal year-end statements must accompany this application. If the financial statements are not on a comparative basis with the prior year, then the three most recent statements must be submitted. The most recent year financial statements must be audited in accordance with Generally Accepted Auditing Standards. If financial statements for the two prior years have been audited in accordance with Generally Accepted Auditing Standards, then those audited financial statements must be submitted as well. If the date of the latest audited financial statements is over six months old at the time of application, interim financial statements up to and including at least the latest fiscal quarter must be included and must be certified as to their accuracy by a corporate officer, general partner, or sole proprietor. All financial information submitted with this application must be in the name entered on Line 1 below. The undersigned employer (hereinafter referred to as the Applicant), an employer subject to the provisions of the Florida Workers' Compensation Law, hereby makes application for the status of a self-insurer in order to pay compensation directly. In connection with such application, the Applicant makes the following declarations for the purpose of enabling the Division of Workers' Compensation (hereinafter referred to as the Division) to make a finding of facts as to whether the Applicant meets the qualifications for self-insurance established in Rule 69L-5, Florida Administrative Code. The Association will review this application and accompanying documents and will advise the Applicant in writing of any additional requirements imposed by Rule 69L-5, Florida Administrative Code. All requirements shall be fulfilled prior to the Division's approval of this application. The approval or denial of this application is governed by Sections 120.57 and 120.60, Florida Statutes and the applicable rules of procedure. In the event this application is denied, the Applicant shall have the right to request an administrative hearing on the denial of the application in accordance with Sections 120.57 and 120.60, Florida Statutes. If all requirements to self-insure are not met within 90 days of the date of application, the Division reserves the right to deny this application without prejudice. 1. Name of Applicant: 2. Applicant's Federal Employer Identification Number: 3. Address (Principal Office): 3a. Telephone Number: 4. Attach a list of all subsidiary or affiliated companies which are to be included under the applicant's self-insurance privilege. Indicate the percentage ownership of the applicant in each subsidiary or affiliated company. Include the address of each Florida location for each subsidiary or affiliated company. 5. Applicant is a (check one): Corporation, Partnership, Individual Proprietorship, Other ______________ Attach proof that applicant or subsidiaries are registered Florida corporations. Form DFS-F2-SI-1 (8/2009) Rule 69L-5.226, F.A.C. Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 6. Name of employee who will coordinate self-insurance program: 6a. Title: 6b. Address if different from #3 above: 6c.Telephone number if different from #3a above: 7. Describe briefly the general nature of the operations performed in Florida or the items manufactured in Florida: 8. Applicant's primary North American Industry Classification (NAIC) Code: 9. Describe briefly all work performed away from Florida locations: 10. Year business established: 11. Did you succeed anyone? If a corporation, under laws of what state? If so, whom? 12. Name of workers' compensation carrier at time of application: 13. What is the renewal date for your current workers' compensation coverage? 14. Attach a completed Certification of Servicing (Form DFS-F2-SI-19). 15. Attach a copy of at least your current experience modification rating, past two (2) if available. 16. Give the following estimated payroll information for your first twelve (12) months of self-insurance. Provide the payroll classifications assigned to your operations using the classification system established by the National Council on Compensation Insurance. AMOUNT OF PAYROLL BY OCCUPATIONAL CLASSIFICATION No. of Employees Occupation Payroll Payroll Class. FOR DIVISION USE ONLY Manual Annual Rate Gross Premium Total Premium $ _________________________ Form DFS-F2-SI-1 (8/2009) Rule 69L-5.226, F.A.C. Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 17. If a corporation, attach a list of the name and city and state of residence of each corporate officer; if a partnership, the name and city and state of residence of each partner; if an individual proprietorship, the name and city and state of residence of the owner. 18. If a limited partnership, give the date of formation and duration of partnership. 19. Is the applicant a subsidiary? If so, give the name and address of parent company: 20. In consideration of the approval of this application, the Applicant hereby expressly understands and agrees to the following: a. To maintain such security deposits and excess insurance as required by the rules of the Division. b. To abide by all provision of Chapter 440, Florida Statutes, the Florida Workers' Compensation Law and all rules of the Division. c. That the authorization to self-insure may be revoked for cause at the discretion of the Division as provided by Section 440.38, Florida Statutes. d. To fully discharge by cash payments all amounts required to be paid by the provisions of the Workers' Compensation Law within the time periods prescribed by law. e. To pay to the Division all assessments required by Chapter 440, Florida Statutes. f. To pay to the Florida Self-Insurers Guaranty Association, Inc. all assessments required by Section 440.385, Florid