Form SI-1 (Rev. 9/96) Page 1 of 3
Form SI-1 (Rev. 9/96)
Page 1 of 3
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 and the application and all accompanying
documents must be filed in duplicate to: Self-Insurance Section, P. O. Box 5497, Tallahassee, Florida 32314-5497.
All financial information submitted with this application must be prepared in accordance with United States
Generally Accepted Accounting Principles. Financial statements must be audited by an independent Certified
Public Accountant or certified true and correct by a corporate officer or owner. Only audited financial
statements may be submitted after January 1, 1997. A current fiscal year ending financial statement as well as
the prior fiscal year ending statement 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. An interim
financial statement for the most recent accounting period, as well as a certification signed by a corporate
officer stating that there has been no material adverse change in the company's financial condition since the
date of the latest year-end financial statement must also be included with this application. 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 Chapter 4L-5, Florida Administrative Code.
The division will review this application and accompanying documents and will advise the applicant in writing
of any additional requirements imposed by Rule Chapter 4L-5. 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 ,
or other ______________
Attach proof that applicant or subsidiaries are registered Florida corporations.
Form SI-1 (Rev. 9/96)
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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 Standard Industrial Classification Code
9. Describe briefly all work performed away from Florida locations
10. Year business established.
If a corporation, under laws of what state?
11. Did you succeed anyone?
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 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 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
FOR DIVISION USE ONLY
No. of
Employees
Occupation
Payroll
Payroll
Class.
Manual Gross
Annual
Rate
Premium
Total Premium $ _________________________
17. If a corporation, attach a list of the name and residence of each corporate officer; if a partnership, the
name and residence of each partner; if an individual proprietorship, the name and residence of the owner.
Form SI-1 (Rev. 9/96)
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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 cash security deposits or surety bonds 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 privilege 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, Florida Statutes and Plan of Operation of the Florida Self-Insurers Guaranty Association, Inc.
g.
That the self-insurance privilege extended upon approval of this application applies only to the
applicant and such businesses or subsidiaries in which it has a majority ownership interest and which
are included on this application.
h.
That other businesses or subsidiaries in which the applicant has majority ownership interest may be
included under its self-insurance privilege upon written notification to the division and after
submitting such financial information and entering into indemnification agreements as the division
may require.
i.
That the self-insurance privilege extended upon approval of this application will not include any
businesses or subsidiaries in which the applicant no longer has a majority ownership interest and such
privilege will expire and terminate without prior notice on the date that the applicant relinquishes a
majority ownership interest.
j.
That the self-insurance privilege extended upon approval of this application will be revoked by the
division when the majority ownership interest of the applicant changes from that indicated by its
application. That is, if the applicant is sold, merged, dissolved or otherwise changes its ownership
interest to the extent that the financial information upon which the self-insurance privilege was
granted can no longer be used to determine the applicant's financial ability to pay compensation
benefits promptly in accordance with the law.
I,
, certify that all businesses included under this application are in
compliance with the coverage requirements of the workers' compensation law contained in Section 440.38(1),
Florida Statutes and that all such businesses will remain in compliance with this section pending approval of
this application. I further certify that all information contained in this application is true and correct to the best
of my knowledge.
Applicant
(Employer Name)
By
(Signature)
Title
(Owner, Partner or Corporate Officer)