FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION BUREAU OF MONITORING AND AUDIT SELF-INSURANCE SECTION REPORT DUE DATE SELF-INSURER PAYROLL REPORT SELF-INSURER'S NAME AND ADDRESS FEIN NUMBER PERIOD COVERED CARRIER NUMBER 999- EXPERIENCE MOD AMOUNT OF PAYROLL BY OCCUPATIONAL CLASSIFICATIONS OCCUPATION MANUAL CLASS PAYROLL* RATE PER $100 PREMIUM * Includes the entire remuneration, whether paid in money or a substitute for money, for services rendered by employee. Payroll should be reported in whole dollars only (no cents) and rounded to the nearest dollar. Overtime should be reported at straight time rate. Executive officer payroll should be limited to the maximum weekly amount. Include explanations for class codes added or deleted and payroll increased or decreased more than 20% from that reported on the report for the previous period. Periods of less than a full year should be annualized for comparison and explanation purposes. IF ANY OF THE INFORMATION ENTERED ON THE FORM IS ILLEGIBLE OR NOT IN COMPLIANCE WITH THE INSTRUCTIONS, THE FORM WILL BE RETURNED UNPROCESSED. PLEASE RETURN COMPLETED REPORT TO: FSIGA MEMBERS Florida Self-Insurers Guaranty Association Inc. 1427 East Piedmont Drive, 2nd Floor Tallahassee, Florida 32308 (850) 222-1882 www.fsiga.org GOVERNMENTALS Division of Workers' Compensation Bureau of Monitoring & Audit, Self-Insurance Section 200 East Gaines Street Tallahassee, Florida 32399-4224 http://www.myfloridacfo.com/WC/ ASSESSMENT COMPUTATIONS WILL BE SENT WITH BILLING FORM DFS-F2-SI-5 (8/2009) Rule 69L-5.203, F.A.C. American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR COMPLETION OF FORM SI-5 SELF-INSURER PAYROLL REPORT IF ANY OF THE INFORMATION ENTERED ON THE FORM(S) IS ILLEGIBLE OR NOT IN COMPLIANCE WITH THESE INSTRUCTIONS, THE FORM(S) WILL BE RETURNED UNPROCESSED. These instructions are to clarify the completion of the form. Some lines are not covered in these instructions as the instructions are included on the form. If you have any questions concerning the form or these instructions, please contact: FSIGA MEMBERS Florida Self-Insurers Guaranty Association Inc. (850) 222-1882 GOVERNMENTALS Division of Workers' Compensation Bureau of Monitoring & Audit, Self-Insurance Section (850) 413-1784 SELF-INSURER NAME AND ADDRESS � This is the name of the authorization holder FEIN � This is the Federal Employer Identification Number of the authorization holder. CARRIER NUMBER � This is the self-insured carrier number assigned to the authorization at the time it was approved. PERIOD COVERED � This is the payroll period to be reflected on the report and should be no more than one full year ending on the day before the authorization holder's most recent anniversary rating date. EXPERIENCE MODIFICATION � This is the experience modification, issued by either the Division of Workers' Compensation or the National Council on Compensation Insurance having an effective date that corresponds to the beginning date of the payroll period covered. If there is no experience modification with an effective date that exactly corresponds to the beginning date of the payroll period covered, then the experience modification in effect on the beginning date of the payroll period covered and any subsequent experience modification(s) with effective date(s) during the payroll period covered will be applied to this report on a weighted average basis. REPORT DUE DATE � This is two months after the ending date of the period covered. OCCUPATION COLUMN � This is the classification code description for the classification number shown in the manual class column as described in the NCCI "Basic Manual for Workers' Compensation and Employers' Liability Insurance" and "SCOPES of Basic Manual Classifications". MANUAL CLASS COLUMN� This is the 4-digit classification code number assigned to a specific type of job by the National Council on Compensation Insurance in accordance with Rule 1 of the NCCI "Basic Manual for Workers' Compensation and Employers Liability Insurance". PAYROLL COLUMN � This is the total payroll paid to employees properly assigned to the classification code shown in the manual class column during the payroll period covered by this report. Payroll includes the entire remuneration, whether paid in money or a substitute for money, for services rendered by an employee and must be reported in accordance with Rule 2 of the NCCI "Basic Manual for Workers' Compensation and Employers Liability Insurance". Overtime payroll (in excess of 40 hours per week) should be reported at the straight time rate. Payroll for executive office should be limited to the maximum allowed by the rate filing in effect at the start of the payroll period covered. RATE PER $100 COLUMN � This is the manual rate assigned to a specific manual class by the rate filing approved by the Dept. of Financial Services and in effect at the start of the payroll period covered. PREMIUM � This is payroll times manual rate divided by 100. INCLUDE EXPLANATIONS FOR CLASS CODES ADDED OR DELETED AND PAYROLL INCREASED OR DECREASED MORE THAN 20% FROM THAT REPORTED ON THE REPORT FOR THE PREVIOUS PERIOD. PERIODS OF LESS THAN A FULL YEAR SHOULD BE ANNUALIZED FOR COMPARISON PURPOSES. FORM DFS-F2-SI-5 (8/2009) Rule 69L-5.203, F.A.C. American LegalNet, Inc. www.FormsWorkFlow.com