Current as of: Dec. 2011 Current Self-Insurers and Former Self-Insurers shall submit loss data for all entities covered under the self-insurance authorization on Form DFS-F2-SI-17 (Unit Statistical Report), effective 08/09, as incorporated by reference, or the electronic equivalent provided by the Department. Copies of this form are available at the Division of Workers’ Compensation, Bureau of Monitoring and Audit, Self-Insurance Section, 2012 Capital Circle, S.E., Hartman Building, Tallahassee, FL 32399-4224. Failure to submit the required loss data forms or material understatement or concealment of data shall constitute good cause for revocation of the self-insurance authorization in addition to civil penalties specified in Rule 69L-5.217, F.A.C. (1) The Division or the Association shall, within at least ten (10) days prior to the evaluation date, advise each self insurer of the covered periods for the submission of the loss data. (2) Current Self-Insurers will complete Form DFS-F2-SI-17 (Unit Statistical Report), effective 08/09, or the electronic equivalent of Form DFS-F2-SI-17 (Unit Statistical Report), effective 08/09, by submitting loss data for the current evaluation year and the prior two (2) evaluation years. (3) Former Self-Insurers shall continue to submit this report until the loss data for the final period of authorization has been reported for three (3) years. (4) The completed Form DFS-F2-SI-17 (Unit Statistical Report), effective 08/09, or the electronic equivalent of Form DFS-F2-SI-17 (Unit Statistical Report), effective 08/09, shall be mailed or transmitted to the Division or the Association no later than sixty (60) days after the evaluation date. (a) Governmental Entities who are unable to transmit an electronic version of Form DFS-F2-SI-17 (Unit Statistical Report), effective 08/09, shall mail the completed Form DFS-F2-SI-17 (Unit Statistical Report), effective 08/09, no later than 60 days after the evaluation date to the: Department of Financial Services Division of Workers’ Compensation Bureau of Monitoring and Audit/Self-Insurance 200 East Gaines Street Tallahassee, Florida 32399-4224 (b) FSIGA Members who are unable to transmit the electronic version of Form DFS-F2-SI-17 (Unit Statistical Report), effective 08/09, shall mail the completed Form DFS-F2-SI-17 (Unit Statistical Report), effective 08/09, to: Florida Self-Insurers Guaranty Association, Inc. 1427 E. Piedmont Dr., 2nd Floor Tallahassee, Florida 32308 (5) The Division will promulgate the experience modification using the NCCI Basic Manual for Workers’ Compensation and Employers’ Liability Insurance and the NCCI Experience Rating Plan Manual for Workers’ Compensation and Employers’ Liability Insurance. The NCCI Experience Rating Plan Manual for Workers’ Compensation and Employers Liability Insurance, 2003 Edition, including updates through October 2008, and the NCCI Basic Manual for Workers’ Compensation and Employers Liability Insurance, 2001 Edition, including updates through June 1, 2009, are previously incorporated by reference into Rule 69L-5.201, F.A.C. (6) The experience modification shall be used in the calculation and collection of assessments for the Workers’ Compensation Administration Trust Fund, the Special Disability Trust Fund, and the Florida Self-Insurers Guaranty Association, Inc. (7) The Division shall provide a copy of the experience rating worksheet to each self-insured employer and FSIGA. Rulemaking Authority 440.38(1), (2), (3), 440.385(6), 440.525(2), 440.591 FS. Law Implemented 440.38(1), (2), (3), 440.385(1), (3), (6), 440.525 FS. History–New 3-9-10. Laws implemented by this Rule: Florida Statutes § 440.38, 440.385,  |  |  | | 
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