Forms and Documents
Compliance Guide for Self-Insurers
This guide is intended to provide your company with information on the filing requirements for individual self-insurers for workers’ compensation pursuant to Section 440.38, Florida Statutes.Continuing Self-Insurance Reporting Requirements for Terminated Self-Insurers
Continuing Self-Insurance Reporting Requirements for Terminated Self-InsurersForm SI-4F - Surety Bond for FSIGA Member
SELF-INSURER'S SURETY BOND FOR FSIGA MEMBERForm SI-5 - Payroll Report (includes instructions)
SELF-INSURER PAYROLL REPORT (includes instructions)FORM SI-5 - EXECUTIVE OFFICER PAYROLL LIMITATION
Form SI-5 Executive Officer Payroll Limitation NoticeForm SI-5 - COVID-19 Payroll Reporting for Furloughed Employees
Form SI-5 COVID-19 Payroll Reporting for Furloughed Employees NoticeForm SI-6 - Letter of Credit (PDF - Acrobat Format)
SELF-INSURER’S IRREVOCABLE LETTER OF CREDITForm SI-6 - Letter of Credit (DOC - Word Format)
SELF-INSURER’S IRREVOCABLE LETTER OF CREDIT. In .DOC format (Microsoft Word compatible).Form SI-10 - Parental Guaranty (PDF - Acrobat Format)
PARENTAL GUARANTY AND CORPORATE RESOLUTION FOR SELF-INSURED SUBSIDIARY ENTITY.Form SI-10 - Parental Guaranty (DOC - Word Format)
PARENTAL GUARANTY AND CORPORATE RESOLUTION FOR SELF-INSURED SUBSIDIARY ENTITY. In DOC format (Microsoft Word compatible).Form SI-11 - Indemnity Agreement
INDEMNITY AGREEMENTForm SI-17 - Unit Statistical Report (includes instructions)
UNIT STATISTICAL REPORTForm SI-17 - Electronic Reporting Excel Training Manual
Self-Insurer Batch SI-17 Statistical Reporting Excel Training ManualForm SI-17 - Electronic Reporting Transmittal Memo
Unit Statistical Report(s) – Optional Electronic Submission RequestFORM SI-17 - Electronic Reporting Excel Template
FORM SI-17 - Electronic Submission Excel TemplateForm SI-17 - Electronic Reporting Text File Formatting Instructions
Self-Insurance Loss Data File Formatting Specifications for the Electronic Submission of Form SI-17 (Self-Insurer Unit Statistical Report)FORM SI-17 - Split Point Change Notice
Form SI-17 Split Point Change For Excess/Non-excess Claim ReportingFORM SI-17 COVID-19 CLAIMS REPORTING MEMO
Reporting claims on Form SI-17 for exclusion of COVID-19 claims from experience rating calculationForm SI-19 - Certification of Servicing
CERTIFICATION OF SERVICING FOR SELF-INSURERSForm SI-20 - Report of Outstanding WC Liabilities (includes instructions)
REPORT OF OUTSTANDING WORKERS’ COMPENSATION LIABILITIESFSIGA Plan of Operation
The current Plan of Operation of the Florida Self-Insurers Guaranty Association, Inc.Rule 69L-5
CHAPTER 69L-5: RULES FOR SELF-INSURERS UNDER THE WORKERS' COMPENSATION ACTGet Acrobat Reader
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