Affiliated Self-Insurers must execute a new Form DFS-F2-SI-11 (Indemnity Agreement), effective 08/09, as incorporated by reference, within thirty (30) days of changes in the affiliates included under the self-insurance authorization. Copies of this form are available at the Division of Workers’ Compensation, Bureau of Monitoring and Audit, Self-Insurance Section, 1579 Summit Lake Drive, Tallahassee, FL 32317. Form DFS-F2-SI-11 (Indemnity Agreement), effective 08/09, shall be executed by an officer of each affiliated entity to be included under the self-insurance authorization. The executed form shall be submitted to the:
Florida Self-Insurers Guaranty Association, Inc.
1427 E. Piedmont Dr., 2nd Floor
Tallahassee, Florida 32308
Rulemaking Authority 440.38(1), (2), (3), 440.385(6), 440.591 FS. Law Implemented 440.38(1), (2), (3), 440.385(1), (3), (6) FS. History-New 3-9-10.