Free SI-19 - Florida

DIVISION OF WORKERS' COMPENSATION BUREAU OF MONITORING AND AUDIT SELF-INSURANCE SECTION CERTIFICATION OF SERVICING FOR SELF-INSURERS NAME OF SELF-INSURER PART I TO BE COMPLETED BY THE SERVICE COMPANY (IF APPLICABLE)

The undersigned service company certifies that the above self-insurer has satisfied the servicing requirements as contained in Rule 4L-5.113, F.A.C., by contracting for the services indicated below on a full time basis beginning on ________________________ and ending on ______________________. INDICATE WITH AN "X": ¨ All (Claims Adjusting, Safety and Underwriting) ¨ Claims Adjusting ¨ Underwriting ¨ Safety The undersigned service company also certifies that its contract with the above self-insurer complies with Rule 4L-5.113, F.A.C. Name of Service Company_______________________________________________________________ Signature ________________________________________ Date _______________________________ Name ____________________________________________ Title _______________________________

PART II

TO BE COMPLETED BY THE SELF-INSURER FOR SERVICES NOT INCLUDED UNDER PART I

The undersigned self-insurer certifies that it has satisfied the servicing requirements as contained in Rule 4L5.113, F.A.C., by contracting with the firms listed below or by use of its own in-house personnel for the indicated services. INDICATE WITH AN "X": ¨ A. Claims: ¨ In-house ¨ Contracting with_______________________________________________ Beginning on __________________and ending on____________________ Note: Submit claims adjusting licenses for contract personnel and resumes or license numbers for in-house personnel. ¨ B. Underwriting: ¨ In-house ¨ Contracting with_______________________________________________ Beginning on __________________and ending on______________ Note: Submit resumes of underwriting personnel. ¨ C. Safety ¨ In-house ¨ Contracting with________________________________________________ Beginning on ______________________and ending on_________________ Note: For in-house safety, submit a copy of your safety program or a letter of approval from the Division of Safety.

PART III

TO BE COMPLETED BY THE SELF-INSURER

The undersigned self-insurer certifies that the information contained on and accompanying this form is true and correct to the best of his/her knowledge. Name of the Self-Insurer________________________________________________________________ Signature_____________________________________________ Date __________________________ Name_______________________________________________ Title____________________________

Form SI-19 (9/96)