Can this report be signed electronically?

Yes. Electronic signatures meet federal ESIGN Act standards (15 U.S.C. ch. 96) and UETA in most states provided the signature shows intent, consent to do business electronically, attribution to the signer, and the record can be retained and reproduced.

Are there cases where e-signatures are not allowed?

Certain documents fall into statutory exceptions such as wills, court orders, and some notices; confirm with the applicable state law before relying on e-signatures for those categories.

What if an employee TIN is missing or incorrect?

Missing or incorrect TINs can trigger backup withholding at 24% and IRC §6721 penalties for incorrect information returns; obtain corrected W-9 information promptly to avoid penalties.

Who must sign the report?

An authorized representative with signing authority for the employer should sign; document authority in corporate minutes or delegation documents to support the signature.

How do I correct errors after submission?

Prepare a corrected report with clear change notes and retain both versions. For tax-related reporting, follow IRS correction procedures for information returns.

How long should I keep the report?

Retain according to the applicable standards: at least 3 years for IRS purposes (IRC §6501(a)) and 6 years for HIPAA-covered records where applicable (45 CFR §164.530(j)).

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Self-Insurer Payroll Report

Self-Insurer Payroll Report

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FLORIDA DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
BUREAU OF MONITORING AND AUDIT
SELF-INSURANCE SECTION

SELF-INSURER'S NAME AND ADDRESS

REPORT DUE DATE

SELF-INSURER PAYROLL REPORT

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.

What the Self-Insurer Payroll Report Is

A Self-Insurer Payroll Report documents wages, payroll taxes, and insurance-related payroll deductions for an employer that operates self-insured benefit plans. The report summarizes employee wages, taxable benefits, employer contributions, and applicable withholdings for a defined reporting period. It is used by payroll administrators, third-party administrators, and state or federal agencies to verify payroll-driven insurance liabilities, tax withholding compliance, and premium or reserve calculations. Accurate reporting supports tax filings, audits, and regulatory reviews and serves as a primary record when reconciling benefits paid from a self-insurance fund.

Why a Complete Report Matters for Compliance and Accuracy

A correct Self-Insurer Payroll Report reduces audit exposure, ensures accurate tax withholding, and documents the payroll basis for self-insurance liabilities. It provides verifiable data used in tax reporting, regulatory reviews, and internal reserve calculations while helping to establish a defensible audit trail.

Primary users and stakeholders

Understanding each party’s role helps assign responsibility for data collection, review, and final sign-off before submission.

Payroll and benefits teams responsible for wage and deduction accuracy.
Third-party administrators who manage claims and reserves for self-insured plans.
Internal and external auditors validating payroll-based liabilities.

Core sections to include in a professional report

A complete report organizes payroll data, summaries, and supporting calculations so reviewers can validate totals and reconcile to tax filings and plan expenditures.

Employer Info

Legal entity name and employer identification number used to match tax filings and insurance registrations; include business address and contact.

Reporting Period

Clear start and end dates for the payroll period with year-to-date totals to align with tax and benefit reporting windows.

Employee Roster

List each employee with SSN or masked identifier, gross wages, taxable benefits, and payroll deductions tied to the self-insured plan.

Tax Withholdings

Breakdown of federal income tax, social security, Medicare, state withholding, and employer payroll tax contributions.

Self-Insurance Charges

Employer and employee shares of self-insurance premiums, stop-loss allocations, or reserve adjustments with calculation notes.

Reconciliation Notes

Explanation of differences from tax returns, adjustments, or retroactive corrections and references to supporting source files.

Required fields and standard data elements

Entity Name: Legal business name

EIN: Employer Identification Number

Reporting Period: MM/DD/YYYY range

Employee Identifiers: SSN or masked ID

Wage Totals: Gross and taxable wages

Payroll Taxes: Withheld and employer shares

Step-by-step: completing the Self-Insurer Payroll Report

Follow these sequential steps to gather data, verify calculations, and finalize the report for submission or internal recordkeeping.

01

Collect payroll data: Export payroll register and benefit deduction detail for the reporting period.
02

Map fields: Match payroll columns to report fields and note any missing data.
03

Reconcile totals: Compare report totals to general ledger and tax filings; document variances.
04

Review and sign: Authorized signer reviews entries, signs, and prepares supporting attachments.

How to configure an online reporting workflow

Set up a digital workflow that enforces required fields, collects approvals, and retains an audit trail for each submission.

Field validation rules	Require EIN, date formats, and numeric wage fields; block submission if missing.
Role-based routing	Route first to payroll, then to benefits manager, then to authorized signatory.
Authentication method	Use email link, SMS code, or stronger verifier for signers as required.
Document retention	Enable tamper-evident storage and exportable audit logs.
Notifications	Configure reminders and status updates for pending approvals.

Where to send or file the completed report

Reports may be retained internally, shared with a third-party administrator, or delivered to a state or federal agency depending on regulatory requirements.

Internal records: Store signed reports with payroll and benefits files for audits.
TPA submission: Send to third-party administrators for claims and reserve reconciliation.
Regulatory filing: File with state insurance or labor departments when required.
Tax authorities: Use supporting data to reconcile W-2/1099 filings to the IRS.

Delivery and eSubmission options

Choose the method that preserves integrity, provides a time-stamped audit trail, and meets any industry-specific authentication requirements.

Document formats: PDF, DOCX, or exported CSV
Integrations: Connectors to payroll or ERP systems
Authentication: Email link, SMS code, or stronger verification

Typical timings and filing expectations

Timing depends on internal payroll cycles, employer self-insurance reporting schedules, and any statutory deadlines tied to tax filings or state reporting.

Payroll cutoff:

Align with payroll period close and payroll register export deadlines.

Internal review:

Allow 3–7 business days for verification and approvals.

Tax reconciliation:

Complete before issuing W-2s or 1099s to avoid mismatches.

Regulatory filing:

Follow state-specific submission deadlines where applicable.

Retention start:

Date retention from the report creation or last effective date.

Common preparation mistakes to avoid

Mismatched names or EINs between payroll and report prevent matching to tax returns and can trigger audits or rework by payroll and finance teams.
Incorrect date ranges or overlapping reporting periods lead to double-counting or omitted wages when reconciling year-to-date totals with tax forms.
Omitting employee identifiers or using inconsistent masking prevents precise claim matching and undermines reserve allocation for the self-insurance fund.
Failure to attach supporting calculations or source exports increases reviewer questions and slows regulatory or internal approvals.

Consequences of incorrect or late reporting

Tax penalties: IRC §6721 penalty tiers apply for incorrect information returns

I-9 exposure: Paperwork fines per 8 CFR §274a.2 if employment records are incomplete

Audit risk: Increased probability of IRS or state audit

Reserve misstatement: Incorrect liabilities affecting solvency assessments

Data breach risk: Poor handling of SSNs and PHI may trigger HIPAA violations

Contract disputes: Misreported payroll can lead to vendor or claimant disputes

Typical eSignature vendor comparison for this report

Comparison of common plan features and starting prices for eSignature providers commonly used to complete and deliver payroll reports.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by plan	Varies by plan	Yes, limited	Yes, limited
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies by plan	Varies by plan	Varies by plan

Frequently asked questions and quick answers

Answers to common questions about e-signing, filing, corrections, and retention for the Self-Insurer Payroll Report.

Need help? Contact support

Can this report be signed electronically?
Yes. Electronic signatures meet federal ESIGN Act standards (15 U.S.C. ch. 96) and UETA in most states provided the signature shows intent, consent to do business electronically, attribution to the signer, and the record can be retained and reproduced.
Are there cases where e-signatures are not allowed?
Certain documents fall into statutory exceptions such as wills, court orders, and some notices; confirm with the applicable state law before relying on e-signatures for those categories.
What if an employee TIN is missing or incorrect?
Missing or incorrect TINs can trigger backup withholding at 24% and IRC §6721 penalties for incorrect information returns; obtain corrected W-9 information promptly to avoid penalties.
Who must sign the report?
An authorized representative with signing authority for the employer should sign; document authority in corporate minutes or delegation documents to support the signature.
How do I correct errors after submission?
Prepare a corrected report with clear change notes and retain both versions. For tax-related reporting, follow IRS correction procedures for information returns.
How long should I keep the report?
Retain according to the applicable standards: at least 3 years for IRS purposes (IRC §6501(a)) and 6 years for HIPAA-covered records where applicable (45 CFR §164.530(j)).

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