Qualified Servicing Entity Annual Report Form {SI-23}

FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION BUREAU OF MONITORING AND AUDIT SELF-INSURANCE SECTION QUALIFIED SERVICING ENTITY ANNUAL REPORT FORM 1. Name of Business_____________________________________ FEIN Number_________________ 2. Address of Home Office ____________________________________________________________ 3. Please note if your home office is not the location of your records, indicate the address of such records __________________________________________________________________________ Please complete the following items only if there has been a change from that reported on your application or on your last annual report. If there has been no change, please write "No Change". Attach additional sheets if necessary. 4. Address, telephone and fax numbers of your Florida branch offices __________________________ ___________________________________________________________________________________ 5. Your business is a Corporation, Partnership, Individual Proprietorship, Other (explain) ________________________________________________________________________________ 6. Name and addresses of owners, partners or corporate officers:_______________________________ ____________________________________________________________________________________ No. If yes, give the name and address of your parent 7. Is your business a subsidiary? Yes company: ________________________________________________________________________ For items 8 and 9, please note any changes from your last annual report or from your original application. Please include residence and business addresses for all new personnel submitting a resume. If your answer is "Yes" to any of these questions, attach summary data on the size and composition of the appropriate staff; include resumes on any new individuals with administrative or professional responsibilities. 8. Have there been any changes in your claims staff? Yes No Yes No 9. Have there been any changes in your safety engineering staff? 10. If substantial changes to safety program have been made, were they approved by the Division of No Workers' Compensation? Yes No (If yes, list the name and 11. Is there a new person to act for your business in Florida? Yes contact information for this person): ________________________________________________________________________________ ________________________________________________________________________________ FORM DFS-F2-SI-23 (8/2009) Rule 69L-5.230, F.A.C. Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 12. Attach a list of all the self-insured employers and self-insurers funds for which you are currently providing service. Please indicate the extent of the services being performed (e.g., claims, safety or all). Please limit your response to Florida Workers' Compensation, Self-Insurers. Indicate if the services being provided are for a current contract or for claims run-off of an expired contract. This form must be returned no later than March 1 each year. If the report is complete, notification of recertification should be received within sixty (60) days. Please send the completed report to: Florida Department of Financial Services Division of Workers' Compensation Bureau of Monitoring & Audit Self-Insurance Section 200 East Gaines Street Tallahassee, FL 32399-4224 I ____________________________________,certify that the information contained in and accompanying this annual report form is true and correct to the best of my knowledge. Date:_______________________ __________________________________________________________ (Name of Qualified Servicing Entity) By:_______________________________________________________ (Signature) Title:______________________________________________________ FORM DFS-F2-SI-23 (8/2009) Rule 69L-5.230, F.A.C. Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com