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Workers Compensation Insurance Florida Office

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SELF-INSURER'S SURETY BOND FOR FSIGA MEMBER

KNOW ALL PERSONS BY THESE PRESENTS:

That , a company authorized to transact surety business in the State of Florida, as Surety, is hereby held and bound to Florida Self-Insurers Guaranty Association, Inc., hereinafter referred to as FSIGA, and to the entitled employees of a self- insured employer, as Principal, in the aggregate sum of Dollars ($) for the payment of which the Surety binds itself, its successors and assigns, jointly and severally with the Principal, by these presents:

WHEREAS, in accordance with the provisions of Section 440.38, Florida Statutes, the Principal has received approval of the Florida Department of Financial Services, Division of Workers' Compensation, hereinafter referred to as the Division, to self-insure, and desires to file this Surety Bond to secure its liability as an employer pursuant to Section 440.38(1)(b), Florida Statutes.

NOW, THEREFORE, it is understood and agreed that:

1. In the event the Principal, as a self-insured employer under the Workers' Compensation Law, fails to pay any of its obligations incurred under the Workers' Compensation Law or the rules and regulations issued thereunder, the Surety binds itself to be primarily liable for and on its own account shall pay and discharge any such obligations to the extent of its remaining liability under this Surety Bond forthwith, after written demand by FSIGA, served personally or by certified mail upon the Surety. FSIGA in its sole discretion may direct in said demand that such sums as may be deemed necessary to secure and discharge any of the aforesaid obligations of the Principal, be paid by the Surety to FSIGA or to a designated claimant or entitled beneficiary or recipient, or that the Surety shall undertake or continue the handling of claims against the Principal and make any appearances before a Judge of Compensation Claims or other court of competent jurisdiction, as an interested party and on its own behalf, the right of FSIGA to make such demand and directions therein being superior and prior to the right of any interested party, beneficiary or recipient.

2. The Surety undertakes and agrees that the obligations of this Surety Bond shall cover and extend to all past, present and future liability of the Principal as a self-insured employer under the Workers' Compensation Law and pursuant to the rules and regulations issued thereunder, and to the extent of its remaining liability under this Surety Bond, to pay said obligations in the manner provided in paragraph 1 above. All liability of the Surety may terminate, however, in accordance with paragraph 3 herein.

3. This Surety Bond may be terminated as of 12:01 a.m. on a specified date by the Surety by and in a written notice of termination given by certified mail to FSIGA at: Florida Self-Insurers Guaranty Association, Inc., 1427 East Piedmont Drive, 2nd Floor, Tallahassee, Florida 32308, and to the Principal. Such termination shall not be effective, however, unless the specified date thereof occurs at least 90 days after the date of receipt by FSIGA of such notice and not earlier. The liability of the Surety shall nevertheless continue as to any and all obligations of the Principal as a self-insured employer under the Workers' Compensation Law to the extent of the liability of the Surety under this Surety Bond, until the acceptance by FSIGA of any new bond or security from or on behalf of the Principal as a substitute for this Surety Bond. FSIGA shall notify the Surety as to the date upon which the substitute new bond or security becomes subject to the claims of Principal's entitled employees or those claiming through such employees.

Such substitute new bond or security shall assume and take over and be subject to the entire liability of this and any previous bond except as to liability already paid or discharged, and the substitute new bond or security posted by the Principal shall be liable for all compensable claims presented against the Principal thereafter, without right of contribution from any prior surety. In no event shall the Surety refuse to honor a legitimate and accurate claim against its Surety Bond solely because of misrepresentations made to the Surety by a previous surety and/or by the Principal to induce the Surety to issue its Surety Bond. The liability of the Surety under this Surety Bond shall not terminate upon the acceptance of any new bond or security from or on behalf of the Principal which is in addition to this Surety Bond. The Surety shall continue to be obligated to the extent of its remaining liability under this Surety Bond prior to the resort to any such additional bond. However, the Surety shall not be liable until all securities including those which were deposited as additional security subsequent to the effective date of this Surety Bond shall have been used.

4. This Surety Bond and the obligations hereunder shall remain and continue in full force and effect so long as the liability of the Principal as a self-insured employer under the Workers' Compensation Law exists.

5. The effective date of this Surety Bond is

6. The identification number for this Surety Bond is

IN WITNESS WHEREOF the Principal has signed or caused this Surety Bond to be duly signed, and its seal hereto affixed at this day of ,20

PRINCIPAL

By

Title

Business Address

IN WITNESS WHEREOF the Surety has signed or caused this Surety Bond to be duly signed, and its seal hereto affixed at this day of ,20

SURETY

By

Title

Business Address

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What the Workers Compensation Insurance Florida Office Is

The Workers Compensation Insurance Florida Office is a standardized administrative document used to report employer insurance details, claims handling contacts, and coverage verification for workplace injuries in Florida. It centralizes the insurer name, policy number, coverage period, employer information, and designated claim representative so state agencies, employers, and medical providers can confirm coverage and routing for benefits. The form supports both paper and electronic completion and may be used by employers, brokers, carriers, and medical providers when authorizing treatment, filing claims, or certifying compensability under Florida law.

Why This Office Form Matters for Compliance and Claims

Accurate completion reduces claim processing delays, ensures correct payer identification, and documents insurer responsibilities for medical and wage-loss benefits under Florida workers' compensation rules. This creates a clear record for audits and helps medical providers secure timely payment.

Why This Office Form Matters for Compliance and Claims

Who Commonly Completes or Receives the Form

Typical participants include employers, insurance carriers, brokers, claims administrators, and treating medical providers.

  • Employers and HR teams provide employer legal name, FEIN, policy number, and contact for claim intake.
  • Insurance carriers or brokers supply policy status, effective dates, claims representative name, and billing instructions.
  • Medical providers and clinics use the form to confirm payer responsibility before initiating treatment or submitting invoices.

Keeping accurate copies with payroll and safety records supports audits, timely bill payment, and regulatory reporting.

Representative Signers and Their Roles

Employer — HR Director

The HR Director or designated employer representative signs to confirm employer identity, worksite address, and that the employee is on the employer payroll. Their signature confirms the employer has reported wages and enrolled in workers' compensation coverage.

Insurer — Claims Manager

A claims manager or authorized carrier representative signs to verify active policy coverage, claim handling contacts, and billing information. This signature binds the insurer's acceptance of claims handling responsibilities for the reported incident.

Essential Sections of a Professional Workers Compensation Insurance Florida Office

A complete form contains identifications, policy details, claim contacts, protocol for medical billing, signature blocks, and retention instructions so all stakeholders can act on a claim without ambiguity.

Employer Information

Full legal business name, DBA if used, FEIN, NAICS code where applicable, primary worksite address, and contact phone/email for claim intake.

Insurance Policy Data

Carrier name, policy number, policy effective and expiration dates, coverage limits, and whether the policy is active for the date of injury.

Claims Contact

Designated claims representative name, phone, email, claim reporting phone number, and preferred claims submission method (fax, portal, email).

Medical Billing Instructions

Provider billing address, payer ID for electronic claims, required claim forms, prior authorization needs, and payment timelines or fee schedules under state rules.

Signature and Certification

Signature block for authorized employer and insurer representatives, printed name, title, and date; include statement certifying the accuracy of provided information.

Document Metadata

Form version, internal control number, and guidance on record retention and how to submit corrected versions if details change.

Required Data Elements and Security Notes

Policy Number: Carrier-issued identifier
Coverage Dates: MM/DD/YYYY to MM/DD/YYYY
Employer FEIN: Federal Employer Identification
Claims Contact: Name, phone, email
Billing Instructions: Payer ID or remittance address
Authorized Signature: Printed name, title, date

Step-by-Step: Completing the Workers Compensation Insurance Florida Office

Follow these steps to fill, verify, and submit the form so claims and medical bills are processed without avoidable interruptions.

  • 01
    Gather Documents: Collect employer tax ID, policy declaration page, and claims contact details.
  • 02
    Enter Identifiers: Populate FEIN, policy number, and worksite address exactly as on official records.
  • 03
    Verify Coverage Dates: Confirm the injury date is within the policy effective period.
  • 04
    Sign and Save: Have authorized parties sign, then retain and distribute copies to providers and claims teams.

How the Form Moves Through Stakeholders

A clear routing path ensures providers, adjusters, and employers have the information needed to act quickly on a new claim.

  • Employer Submission: Employer completes and forwards the form to the insurer or broker.
  • Insurer Confirmation: Carrier verifies coverage, fills claim contact, and countersigns where required.
  • Provider Verification: Medical provider uses the completed form to confirm payer responsibility before treating.
  • Claims Intake: Claims admin receives the form, creates a claim file, and notifies the employer and provider.

Configuring an Electronic Workflow for the Form

Set up fields, authentication, and routing in your eSignature platform to match your claims process and recordkeeping obligations.

Field Configuration
Policy Number Field Required, single-line text
Coverage Dates Date fields with MM/DD/YYYY validation
Claims Contact Grouped name, phone, email fields
Signature Signer-assigned eSignature with timestamp

Digital Submission Considerations and Platform Needs

Choose eSignature and storage settings that meet legal, security, and operational requirements for Florida workers' compensation records.

  • Format Support: PDF and DOCX accepted for archival and exchange
  • Authentication: Email link, SMS code, or stronger KBA/2FA for high-risk workflows
  • Integrations: Support for EDI/payer portals, claims systems, or cloud storage

Ensure any chosen platform supports audit trails, secure storage (AES-256 at rest, TLS 1.2/1.3 in transit), and, where necessary, a BAA for HIPAA-covered data.

Key Deadlines and Timing Expectations

Observe reporting and retention timelines to meet Florida and federal requirements and avoid administrative penalties or delayed payments.

Initial Employer Report:

File to carrier per Florida deadlines — notify insurer promptly after knowledge of injury

Provider Billing:

Submit medical bills according to carrier billing rules and state fee schedules

Claims Acknowledgment:

Carriers typically acknowledge claims within 14–30 days depending on case complexity

Corrected Forms:

Submit corrected forms immediately upon discovering errors to prevent payment denials

Retention Start:

Retention begins on date of creation or last effective date for recordkeeping purposes

Milestone Timeline from Injury to Claim File Creation

A sequential view of critical processing stages helps coordinate employer, provider, and insurer actions after a workplace injury.

01

Injury Reported

Employee reports injury to employer and incident details are recorded.

02

Form Completed

Employer or broker completes the Workers Compensation Insurance Florida Office form.

03

Carrier Confirms

Insurer verifies coverage and provides claims contact and billing instructions.

04

Claim File Opened

Claims administrator opens a file, assigns adjuster, and notifies stakeholders.

Common Errors to Avoid

  • Incorrect policy number entry that prevents electronic matching and delays adjudication.
  • Mismatched employer name or FEIN that leads to payer rejections or backup withholding triggers.
  • Missing or unclear claims contact causing providers to bill incorrectly or pursue collections.
  • Unsigned or improperly authorized signatures, especially where the signer lacks delegated authority.

Penalties and Operational Risks from Incorrect Forms

Payment Delays: Medical bills and wage-loss payments may be postponed
Claim Denial: Carrier may deny or dispute compensability
Regulatory Fines: State penalties or administrative sanctions possible
Audit Exposure: Inaccurate records increase audit risk
Recovery Actions: Subrogation or cost recovery complications may arise
Reputational Risk: Provider relations and employee trust may suffer

eSignature Vendor Price and Feature Comparison for This Form

Compare basic price and key capabilities relevant to processing the Workers Compensation Insurance Florida Office; signNow is listed first per vendor ordering conventions.

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 vendor Varies by vendor Varies by vendor Varies by vendor
Bulk Send Yes (Business Premium) Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Frequently Asked Questions About the Workers Compensation Insurance Florida Office

Answers to common questions about completing, signing, and retaining the form, and how electronic signatures affect validity and submission.


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