Florida Regulations 69L-5.103
§ 69L-5.103 Application. (repealed)
(1) Applications for self- insurance shall be considered for approval based upon the applicant having sufficient financial strength, as determined by a review of the financial statements, to ensure the payment of all current and estimated future claims when due.
(2) Applications for self-insurance shall be made in writing on LES Form |^SI-I| submitted in duplicate at least ninety (90) days prior to the desired effective date to allow for sufficient processing time. The application form, LES Form |^SI-I|is hereby incorporated by reference into rule chapter 38F-5, F.A.C. The version of the form required by this rule shall bear the date September 1996(9/96). A copy of LES Form |^SI-I| may be obtained from the Workers' Compensation, Bureau of Operations Support, Self-Insurance Section, Forrest Building, 2728 Centerview Drive, Tallahassee, FL 32399-4002. All effective dates will be the first day of the month following application approval, or the first day of a month selected by the applicant, providing their application has been approved, but on no occasion will the effective date be more than three months from the approval date. As a general guideline, applications submitted less than ninety (90) days in advance cannot be assured of being granted the requested effective date.
(3) Applications shall be accompanied by two copies of:
(a) The most recent past three years' financial statements in the name of the applicant.
(c) A list of all subsidiary companies which the applicant intends to include under its self-insurance privilege. The list shall include the percentage of the applicant's ownership interest in each subsidiary.
(d) Certification by a corporate officer stating that the applicant, at the time of application, and until approval of application, is in compliance with s. 440.38(1), Florida Statutes.
(e) Experience modification work sheet for the current and two preceding years as set forth in the National Council on Compensation Insurance, Inc. (NCCI) Experience Rating Plan Manual for Workers' Compensation and Employers Liability Insurance, which is hereby incorporated by reference into rule chapter 38F-5, F.A.C. The Manual required by this rule shall bear the date September 1984, and shall include all issued updates. A copy of the Manual and a one-year subscription to any and all updates may be obtained from the National Council on Compensation Insurance, Inc. 750 Park of Commerce Drive, Boca Raton, FL 33487, telephone 800-622-4123, at a cost of $95. A copy of the Manual is also available for viewing at the Division of Workers' Compensation, Bureau of Operations Support, Self-Insurance Section, Forrest Building, 2728 Centerview Drive, Tallahassee, FL 32399-4002.
(f) A minimum initial security deposit, in addition to the security requirements for excess retention, of $ 100,000. If the last three years' losses not fully funded by insurance, reinsurance or subject to reimbursement exceed $100,000, a security deposit equal to those losses must be posted. (To be provided prior to issuance of certificate of self-insurance).
(g) Maximum excess insurance retention of $350,000 or 1% of tangible net worth, whichever is greater.
(4) Upon receipt of the application, the division shall review the application and request any additional information which may be necessary to render a decision on the application.