FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION BUREAU OF MONITORING AND AUDIT SELF-INSURANCE SECTION CERTIFICATION OF SERVICING FOR SELF-INSURERS NAME OF SELF-INSURER: PART I -CLAIMS (Both Current and Former Self-Insurers must complete this part) SECTION A - HANDLING OF THE SELF-INSURED CLAIMS Indicate how the self-insured claims are currently being administered: (Check One) All self-insured claims are being handled by one Qualified Servicing Entity (This Qualified Servicing Entity must execute Section B) Self-insured claims are split between multiple Qualified Servicing Entity (Attach a list of those Qualified Servicing Entity and the dates of self-insurance that each one handles; you must execute a separate Form SI-19 with each Qualified Servicing Entity completing Section B) All self-insured claims are being handled through an approved self-servicing arrangement (Continue in Section C) Self-insured claims are split between a Qualified Servicing Entity, or multiple Qualified Servicing Entities and an approved self-servicing arrangement (Attach a list of those Qualified Servicing Entities and the dates of self-insurance handled inhouse and by each Qualified Servicing Entity) _________________________________________________________________________________________________ _ SECTION B - SERVICING OF SELF-INSURED CLAIMS BY AN APPROVED QUALIFIED SERVICING ENTITY (To be completed by Approved Qualified Servicing Entity if applicable) The undersigned Qualified Servicing Entity certifies that the above self-insurer has satisfied the servicing requirements as contained in Rule 69L-5.230, FAC, relating to claims handling, by contracting for these services on a full-time basis. This contract begins on _________________ and ends on _________________. The dates of self-insurance being serviced by the undersigned Qualified Servicing Entity are ______________ to ______________. The undersigned service company also certifies that its contract with the above self-insurer complies with Rule 69L-5.230, FAC. If this is a new contract and the self-insurer is changing servicing entities, are the previous self-insured claims being transferred to the new Qualified Servicing Entity? Yes (Claims Transferred) No (Claims Remaining) Name of Qualified Servicing Entity for Claims Handling___________________________________________________________________________ Signature ______________________________________________________________ Date _____________________________________________ Name _________________________________________________________________ Title _____________________________________________ Address _______________________________________________________________Telephone _________________________________________ SECTION C - SERVICING SELF-INSURED CLAIMS BY APPROVED SELF-SERVICING ARRANGEMENT (To be completed by the Self-Insurer if claims are being serviced in-house) The undersigned self-insurer certifies that it has satisfied the servicing requirements as contained in 69L-5.216, FAC, relating to claims handling, by use of an approved self-servicing arrangement effective _________________________. (Attach a current Division of Worker's Compensation approval for the self-servicing arrangement; a current approval is within the last three years). PART II - SAFETY (Only Active Self-Insurers must complete this part) The undersigned self-insurer certifies that it has satisfied the servicing requirements as contained in Rule 69L-5.216, FAC, relating to its safety program, in the following manner (check one): By use of an approved self-servicing arrangement (in-house safety program) (Attach a current Division of Workers' Compensation approval for the self-servicing arrangement; a current approval is within the last three years.) By contracting with an approved Qualified Servicing Entity for safety (must insert name of Qualified Servicing Entity below): Name of Qualified Servicing Entity for safety ________________________________________________________ PART III - SELF-INSURER'S CERTIFICATION (Both Current and Former Self-Insurers must complete this part) The undersigned self-insurer certifies that the information contained on and accompanying this form is true and correct to the best of his/her knowledge and that the claims serviced in this manner include all claims covered under this selfinsurance privilege and any other self-insurance privileges assumed by the self-insurer as a result of purchases or mergers. Name of the Self-Insurer______________________________________________________________________________________________________ Signature __________________________________________________________ Date ___________________________________________________ Name _____________________________________________________________ Title ___________________________________________________ PLEASE RETURN COMPLETED CERTIFICATION TO: FSIGA MEMBER: Florida Self-Insurers Guaranty Association, Inc., 1427 East Piedmont Drive, 2nd Floor, Tallahassee, Florida 32308. GOVERNMENTALS: Division of Workers' Compensation, Bureau of Monitoring and Audit, Self-Insurance Section, 200 East Gaines Street, Tallahassee, Florida 32399-4224. Form DFS-F2-SI-19 (8/2009) Rules 69L-5.216 & 69L-5.223, F.A.C. American LegalNet, Inc. www.FormsWorkFlow.com