Florida Regulations 69H-2.004: Certificate of Coverage
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(1) The Department shall adopt and use a Certificate of Coverage form indicating the insured agency and the coverage provided by the Fund.
(2) Form DFS-D0-867, “”State Employee Workers’ Compensation and Employer’s Liability Certificate of Coverage,”” (Effective 07/23), incorporated herein by reference, will be used to provide employee workers’ compensation and employer’s liability coverage to the agency named on the certificate. A copy of the form is available at http://www.flrules.org/Gateway/reference.asp?No=Ref-15485.
(3) Form DFS-D0-863, “”General Liability Certificate of Coverage,”” (Effective 07/23), incorporated herein by reference, will be used to provide general liability insurance coverage to the agency named on the certificate. A copy of the form is available at http://www.flrules.org/Gateway/reference.asp?No=Ref-15482.
(4) Form DFS-D0-864, “”Automobile Liability Certificate of Coverage,”” (Effective 07/23), incorporated herein by reference, will be used to provide fleet automobile liability coverage to the agency named on the certificate. A copy of the form is available at http://www.flrules.org/Gateway/reference.asp?No=Ref-15483.
(5) Form DFS-D0-864A, “”State Risk Management Trust Fund Addendum to Automobile Liability Certificate of Coverage for Off-Duty Law Enforcement Vehicle Property Damage,”” (Rev. 11/05), incorporated herein by reference, will be used to provide an addendum to automobile liability coverage to the agency named on the certificate.
(6) Form DFS-D0-865, “”Federal Civil Rights Liability and Employment Discrimination Certificate of Coverage,”” (Effective 07/23), incorporated herein by reference, will be used to provide coverage for federal civil rights actions under 42 U.S.C. § 1983 or similar federal statutes to the agency named on the certificate. A copy of the form is available at http://www.flrules.org/Gateway/reference.asp?No=Ref-15494.
(7) Form DFS-D0-862, “”Court Awarded Attorney Fees Certificate of Coverage,”” (Rev. 11/05), incorporated herein by reference, will be used to provide coverage for court awarded attorney’s fees in other proceedings against the agency named on the certificate.
(8) Form DFS-D0-1994, Firefighter Cancer Benefits Certificate of Coverage, (Effective 07/23), incorporated herein by reference, will be used to provide coverage for firefighter cancer benefits payable under Florida Statutes § 112.1816(2) A copy of the form is available at http://www.flrules.org/Gateway/reference.asp?No=Ref-15492.
(9) Copies of these forms are available from the Division of Risk Management, Department of Financial Services, 200 East Gaines Street, Tallahassee, FL 32399-0337, or at https://myfloridacfo.com/Division/Risk/.
Rulemaking Authority 284.311, 284.39 FS. Law Implemented 284.30, 284.31 FS. History-New 7-29-72, Formerly 4-30.05, 4-30.005, Amended 1-7-92, 6-28-01, Formerly 4H-2.004, Amended 5-4-05, 7-23-06, 7-18-23.
(2) Form DFS-D0-867, “”State Employee Workers’ Compensation and Employer’s Liability Certificate of Coverage,”” (Effective 07/23), incorporated herein by reference, will be used to provide employee workers’ compensation and employer’s liability coverage to the agency named on the certificate. A copy of the form is available at http://www.flrules.org/Gateway/reference.asp?No=Ref-15485.
(3) Form DFS-D0-863, “”General Liability Certificate of Coverage,”” (Effective 07/23), incorporated herein by reference, will be used to provide general liability insurance coverage to the agency named on the certificate. A copy of the form is available at http://www.flrules.org/Gateway/reference.asp?No=Ref-15482.
(4) Form DFS-D0-864, “”Automobile Liability Certificate of Coverage,”” (Effective 07/23), incorporated herein by reference, will be used to provide fleet automobile liability coverage to the agency named on the certificate. A copy of the form is available at http://www.flrules.org/Gateway/reference.asp?No=Ref-15483.
(5) Form DFS-D0-864A, “”State Risk Management Trust Fund Addendum to Automobile Liability Certificate of Coverage for Off-Duty Law Enforcement Vehicle Property Damage,”” (Rev. 11/05), incorporated herein by reference, will be used to provide an addendum to automobile liability coverage to the agency named on the certificate.
(6) Form DFS-D0-865, “”Federal Civil Rights Liability and Employment Discrimination Certificate of Coverage,”” (Effective 07/23), incorporated herein by reference, will be used to provide coverage for federal civil rights actions under 42 U.S.C. § 1983 or similar federal statutes to the agency named on the certificate. A copy of the form is available at http://www.flrules.org/Gateway/reference.asp?No=Ref-15494.
(7) Form DFS-D0-862, “”Court Awarded Attorney Fees Certificate of Coverage,”” (Rev. 11/05), incorporated herein by reference, will be used to provide coverage for court awarded attorney’s fees in other proceedings against the agency named on the certificate.
(8) Form DFS-D0-1994, Firefighter Cancer Benefits Certificate of Coverage, (Effective 07/23), incorporated herein by reference, will be used to provide coverage for firefighter cancer benefits payable under Florida Statutes § 112.1816(2) A copy of the form is available at http://www.flrules.org/Gateway/reference.asp?No=Ref-15492.
(9) Copies of these forms are available from the Division of Risk Management, Department of Financial Services, 200 East Gaines Street, Tallahassee, FL 32399-0337, or at https://myfloridacfo.com/Division/Risk/.
Rulemaking Authority 284.311, 284.39 FS. Law Implemented 284.30, 284.31 FS. History-New 7-29-72, Formerly 4-30.05, 4-30.005, Amended 1-7-92, 6-28-01, Formerly 4H-2.004, Amended 5-4-05, 7-23-06, 7-18-23.