Current through Reg. 50, No. 187; September 24, 2024
(1) OIR forms adopted. The OIR forms set
forth in paragraphs (a) through (aa) of this subsection, as well as the
accompanying instructions to the forms, are hereby incorporated into rule
Chapter 69O-190, F.A.C., by reference. Copies of the forms are available from
the Bureau of P & L Insurer Solvency, Office of Insurance Regulation,
Tallahassee, Florida 32399-0300.
(a) OIR Form
BSI-1, Application for Self-Insurance.
(b) OIR Form BSI-2, Employer Application for
Group Coverage.
(c) OIR Form BSI-3,
Membership Application.
(d) OIR
Form BSI-3A, Self-Insurers Fund Member Application Monthly Change
Sheet.
(e) OIR Form BSI-4, Revised
Self-Insurers Surety Bond (Guaranty Fund Member).
(f) OIR Form BSI-4A, Self-Insurers Surety
Bond (Guaranty Fund Non-Member).
(g) OIR Form BSI-4B, Self-Insurers Surety
Bond.
(h) OIR Form BSI-5, Payroll
Report, and the accompanying instructions.
(i) OIR Form BSI-6, Self-Insurance Letter of
Credit.
(j) OIR Form BSI-11,
Indemnity Agreement.
(k) OIR Form
BSI-12, Drug-Free Workplace Program.
(l) OIR Form BSI-17, Unit Statistical Report,
and the accompanying instructions.
(m) OIR Form BSI-19, Certification of
Servicing for Self-Insurance.
(n)
OIR Form BSI-20, Report of Workers' Compensation Liabilities.
(o) OIR Form BSI-21, Breakdown of Policy Year
Expenses.
(p) OIR Form BSI-22,
Service Company Application.
(q)
OIR Form BSI-23, Service Company Annual Report Form.
(r) OIR Form BSI-24, Quarterly Status
Report.
(s) OIR Form BSI-24A,
Preferred Payment Plan Quarterly Report.
(t) OIR Form BSI-26, Checklist for the
Submission of Loss Reserve Reports.
(u) OIR Form BSI-27, Biographical
Statement.
(v) OIR Form BSI-28,
Quarterly Financial Statement.
(w)
OIR Form BSI-29, Annual Financial Statement.
(x) OIR Form BSI-30, Report on Preferred
Payment Plan.
(y) OIR Form BSI-31,
Audit Procedures for Contractor/Independent Contractor Relationship.
(z) OIR Form BCM 201, Notice of Termination.
(aa) OIR Form BSI 206, Certificate
of Self-Insurance, and the accompanying instructions.
(2) NAIC forms, instructions and manuals
adopted. The NAIC forms, instructions and manual set forth in subparagraphs (a)
through (e) of this subsection are hereby incorporated into rule Chapter
69O-190, F.A.C., by reference. Copies of the forms are available from the
National Association of Insurance Commissioners, 120 West 12th Street, Suite
1100, Kansas City, Missouri 64105, and are available for inspection during
regular business hours at the Office at its headquarters in Tallahassee,
Florida.
(a) The 1992 National Association of
Insurance Commissioners Quarterly Statement, Fire and Casualty Companies
Association Edition.
(b) The Jurat
Page; Statutory Balance Sheet; Underwriting and Investment Exhibit - Income
Statement; Cash Flow; Underwriting and Investment Exhibit Part 1, Part 1A, Part
2, Part 2A, Part 3, Part 3A and Part 4; Exhibit 1 - Analysis of Assets; Exhibit
2 - Analysis of Non-Admitted Assets; Notes to Financial Statements; Five Year
Historical Data (NOTE: funds shall complete this form on a going forward
basis); Schedule of Special Deposits; Schedule A Part 1; Schedule B; Schedule
BA; Schedule C; Schedule D Part 1, Part 1A, Part 3, Part 4 and Part 5 (NOTE:
only 4th quarter transactions need to be reported); Schedule DA Part 1;
Schedule F - Part 1A (NOTE: any amounts in dispute must be disclosed), Schedule
M; Schedule N; Schedule P, Part 1 Summary, Part 2 Summary, Part 3 Summary, Part
5 Summary, Interrogatories; Schedule X; Schedule Y of the 1992 National
Association of Insurance Commissioners Annual Statement, Fire and Casualty
Companies Association Edition.
(c)
The NAIC's Annual Statement Instructions, Property and Casualty, 1993
edition.
(d) The NAIC's Accounting
Practices and Procedures Manual for Property and Casualty Insurance Companies,
1993 edition.
(e) The NAIC's
Financial Condition Examiner's Handbook, 1993
edition.
Rulemaking Authority 440.5705, 440.591, 624.4621 FS. Law
Implemented 440.381, 440.5705, 624.316, 624.424, 614.4621
FS.
New 12-19-93, Formerly 38F-5.074,
4-190.074.
