Florida Regulations 69L-5.117

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§ 69L-5.117 Forms, Manuals, and Instructions. (repealed)

Repealed. (03-09-10)

(1) Forms adopted. The forms set forth in paragraphs (a) through (p) of this subsection, as well as the accompanying instructions to the forms, are hereby incorporated into Chapter 4L-5, F.A.C., by reference. Copies of the forms are available from the Division of Workers' Compensation, Bureau of Monitoring and Audit, Self-Insurance Section, 200 East Gaines Street, Tallahassee, Florida 32399-4224. (a) |^Form SI-1|, Application for Self-Insurance (Rev. 9/96). (b)|^Form SI-1a|, Re-Application for Self-Insurance (Rev. 9/96). (c) |^Form SI-4|, Revised Self-Insurers Surety Bond (Guaranty Fund Member) (Rev. 9/96). (d) |^Form SI-4B|, Self-Insurers Surety Bond (Rev. 9/96). (e) |^Form SI-5|, Payroll Report, and the accompanying instructions (Rev. 9/96). (f) |^Form SI-6|, Self-Insurance Letter of Credit (Rev. 9/96). (g) |^Form SI-11|, Indemnity Agreement (Rev. 9/96). (h) |^Form SI-17|, Unit Statistical Report, and the accompanying instructions (Rev. 9/96). (i) |^Form SI-19|, Certification of Servicing for Self-Insurance (Rev. 9/96). (j) |^Form SI-20|, Report of Workers Compensation Liabilities (Rev. 9/96). (k) |^Form SI-22|, Service Company Application (Rev. 9/96). (l) |^Form SI-23|, Service Company Annual Report Form (Rev. 9/96). (m) |^Form SI-26|, Actuarial Report Checklist (Rev. 9/96). (n) |^Form SI-27|, Biographical Statement (Rev. 9/96). (o) |^Form SI-32|, Assignment of Securities (Rev. 9/96). (p) |^Form SI-206|, Certificate of Self-Insurance, and the instructions (Rev. 9/96). (q) |^NCCI Form 9|, Drug-Free Workplace Credit (5/7/96). (2) In addition to the forms incorporated in paragraph (1), the following manuals and forms are incorporated by reference: (a) Best's Insurance Reports, Property - Liability (1996 edition). (b) National Council on Compensation Insurance SCOPES of Basic Manual Classifications (January 1997 reprint). (c) National Council on Compensation Insurance Basic Manual for Workers' Compensation and Employers Liability Insurance (1996 edition as revised). (d) National Council on Compensation Insurance Statistical Plan Manual (1984 edition as revised). (e) National Council on Compensation Insurance Experience Rating Plan Manual for Workers' Compensation and Employers Liability Insurance (9/84 as amended). (f) |^UCC 1 Form|, State of Florida Financing Statement (Rev. 1993). (g) Financial Accounting Standards Board Statement 113 (eff. 12/92). (h) GAAP Interpretation and Application of Generally Accepted Accounting Principles, copyright John Wiley & Sons, Inc., 1996. Specific Authority 440.57, 440.5705, 440.591 FS. Law Implemented 440.381, 440.57, 440.5705, 624.316, 624.424 FS. History-New 5-19-97, Formerly 38F-5.117.