Fill and Sign the Name of Business Fein Number Form

FORM DFS-F2 -SI -23 (8/2009) Page 1 of 2 Rule 69L-5.230 , F.A.C . FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION BUREAU OF MONITORING AND AUDIT SELF -INSURANCE SECTION QUALIFIED SERVICING ENTITY ANNUAL REPORT FORM 1. Name of B usiness___________________________ __________ FEIN Number____________ _____ 2. Address of H ome O ffice _____________________________________________________ _______ 3. Please note if your home office is not the location of your records, indica te the address of such records _____________________________________________ _____________________________ Please complete the following items only if there has been a change from t hat reported on your application or on your last annual report. If there has been no change, please write "No Change". Attach additional sheets if necessary. 4. Addre ss, telephone and fax numbers of your Florida branch o ffices _______________________ ___ _____________________________________________________ ______________________________ 5. Your business is a Corporation , Partnership, Individual Proprietorship , Other (explain) ___________________________________________________ _____________________________ 6. Name and addresses of owners, partners or corporate officer s:_______________________________ ____________________________________________________ ________________________________ 7. Is your business a subsidiary? Yes No. If yes, give the name and addres s of your parent company: _____________________________________________________ ___________________ For items 8 and 9, please note any changes from your last annua l report or from your original application. Please include residence and business addresses for all new personnel submitting a resume . If your answer is " Yes" to any of these questions, attach summary data on the size and composition of the appropriate staff; include resumes on any new individua ls with administrative or professional responsibilities . 8. Have there been any changes in your claims staff ? Yes No 9. Have there been any changes in your safety engineering staff ? Yes No 10. If substantial changes to safety program have been made , were they approved by the Division of Workers’ Compensation ? Yes No 11. Is there a new person to act for your business in Florida? Yes No (If yes, list the name and contact information for this person ): _ ____________________________________________________ ___________________________ ____________________________________________________ ____________________________ FORM DFS-F2 -SI -23 (8/2009) Page 2 of 2 Rule 69L-5.230 , F.A.C . 12. Attach a list of all the self -insured employers and self -insurers funds for which you are currently providing service . Please indicate the extent of the services being performed (e.g., claims, safety or all) . Please limit your response to Florida Workers' Compensation , Self -Insurers . Indicate if the services being provided are for a current contract or for claims run -off of an expired contract. Th is form must be returned no later than March 1 each year . If the report is complete, notification of recertification should be received within sixty (60) days. Please send the completed report to: Florida Department of Financial Services Division of Worke rs' Compensation Bureau of Monitoring & Audit Self -Insurance Section 200 East Gaines Street Tallahassee, FL 32399 -4224 I ____________________________________, certify that the information contained in and accompanying this annua l report form is true and correct to the best of my knowledge. Date:_______________________ _____________________________________________________ _____ (Name of Qualified Servicing Entity ) By:____________________________________________________ ___ (Signature) Title:_________________________________________________ _____