Form Si-23 - Service Company Annual Report Form printable pdf download

DIVISION OF WORKERS' COMPENSATION

BUREAU OF MONITORING AND AUDIT

SELF-INSURANCE SECTION

SERVICE COMPANY ANNUAL REPORT FORM

1. Name of business___________________________________________________________________

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 of your Florida branch offices___________________________________________________

____________________________________________________________________________________

5. Your business is a Corporation ( ) Partnership( ) Individual Proprietorship( )

Other( )____________________________________________________________________________

6. Name and addresses of owners, partners or corporate officers:_______________________________

____________________________________________________________________________________

7. Is your business a subsidiary? Yes( ) No( ). If yes, give the name and address of your parent 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( )

9. Have there been any changes in your underwriting staff:

Yes( )

No( )

10. Have there been any changes in your safety engineering staff?

Yes( )

No( )

11. If you have made substantial changes in your safety program, have they been approved by the Division of

Workers’ Compensation?

Yes( )

No( )

12. Do you wish to name a new person to act for your business in Florida? Yes( )

No( ) If yes, list the name,

address and telephone number of that

person:________________________________________________________

_________________________________________________________________________________________

Form SI-23

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Form Si-23 - Service Company Annual Report Form