Fill and Sign the Name of Self Insurer Form

Form DFS-F2-SI -19 (8/2009) Rules 69L -5.216 & 69L -5.223, F.A.C. 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 (B oth Current and Former Self -Insurers m ust 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 o ne 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 -servicin g 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 in -house and by each Qualified Servicing Entity ) ________________________________________________________________________\ _________________________ _ SECTION B - SERVICING OF SELF -INSURED CLAIMS BY AN APPROVED QUALIFIED SERVICING ENTITY (T o be completed by A pproved Qualified Servicing Entity if applicable ) T he undersigned Qualified Servicing Entity certifie s that the above self -insurer has satisfied the servicing require ments as contained in Rule 69L -5. 230, FAC, relating to claims handling , by contracting for the se 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 ______________. T he 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 - SERVICIN G SELF-INSURED CLAIMS BY APPROVED SELF -SERVICING ARRANGEMENT ( To be completed by the S elf-I nsurer if claims are being serviced in -house) The undersigned self -insurer certifie s that it has satisfied the servicing requirements as contained in 69L -5. 216, FAC , relat ing to claims handling, by use of an approved self -servicing arrangement effective ____ _____________________ . (Attach a current Division of Work er’s Compensation approval for the self -serv icing arrangement; a current approval is within the last three year s). 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 ma nner (check one):  By use of an approved self -servicing arrangement (in -house safety program) (Attach a current Division of Work ers’ Compensation approval for the s elf-servicing arrangement; a current approval is within the last three years.)  By contracting with an appr oved 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 C urrent 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 in clude all claims covered under this self-insurance 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, 2 nd 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.