Form DFS-H2-376 "Application for Life License and Appointment - U.S. Foreign Military Installation" - Florida

What Is Form DFS-H2-376?

This is a legal form that was released by the Florida Department of Financial Services - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2017;
  • The latest edition provided by the Florida Department of Financial Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DFS-H2-376 by clicking the link below or browse more documents and templates provided by the Florida Department of Financial Services.

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Download Form DFS-H2-376 "Application for Life License and Appointment - U.S. Foreign Military Installation" - Florida

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F
D
F
S
LORIDA
EPARTMENT OF
INANCIAL
ERVICES
Division of Insurance Agent and Agency Services – Bureau of Licensing
Application for Life License and Appointment
U.S. Foreign Military Installation
Applicant for license/appointment for a natural person, not a resident of this state, to represent an authorized life insurer
domiciled in this site or an authorized foreign life insurer which maintains a regional home office in this state, provided
such person represents such insurer exclusively on a united states military installation located in a foreign country.
(Section 626.322, F.S.)
Application is hereby made for license/appointment, description shown below (Print or Type All):
1. Name_________________________________________________________________________________________
Last
First
MI
2. Social Security Number: _________________ Place of Birth: ___________________ Date of Birth: __________
4. Resident Address: ______________________________________________________________________________
Street
City
State
Zip Code
5. Last address in U.S.: ____________________________________________________________________________
Street
City
State
Zip Code
I, the undersigned, for and on behalf of the insurance company, whose name appears upon, do hereby certify that the
individual for whom a license/appointment is requested, has been thoroughly investigated as to integrity and character;
that he has the necessary training to hold himself out as a life insurance representative; and this company is willing to be
bound by the acts of such applicant within the scope of his employment.
Life Insurance Company Name: ____________________________________________, Company Code: __________
Home Office Address (FL): __________________________________________________________________________
Street
City
State
Zip Code
Mailing Address in Foreign Country (For ALL of your correspondence):
______________________________________________________________________________________________
Sworn to and subscribed before me this _____ day of
_______________, 20_____
_____________________________________________
Company Official (Print/Sign)
_____________________________________________
______________________________________________
Title
Date
Notary Public (Print/Sign)
______________________________________________
City
State
Mail Completed Form to:
(Print, Type, or Stamp Commissioned Name of Notary)
Revenue Processing Section
P.O. Box 6000
Personally Known OR
Produced Identification
Tallahassee, FL 32314-6000
Type of Identification Produced: ___________________
My Commission Expires: _________________________
FEES ARE NON-REFUNDABLE
(SEAL)
Application for License-Filling Fee
$ 50 0093 (F)
I.D. License Fee
$ 5 0090 (F)
Appointment Fee
$ 20 0093 (L)
TOTAL FEES ENCLOSED:
$_____________
Page 1 of 2
DFS-H2-376
Rule 69B-211.002, F.A.C.
Revision 03/17
F
D
F
S
LORIDA
EPARTMENT OF
INANCIAL
ERVICES
Division of Insurance Agent and Agency Services – Bureau of Licensing
Application for Life License and Appointment
U.S. Foreign Military Installation
Applicant for license/appointment for a natural person, not a resident of this state, to represent an authorized life insurer
domiciled in this site or an authorized foreign life insurer which maintains a regional home office in this state, provided
such person represents such insurer exclusively on a united states military installation located in a foreign country.
(Section 626.322, F.S.)
Application is hereby made for license/appointment, description shown below (Print or Type All):
1. Name_________________________________________________________________________________________
Last
First
MI
2. Social Security Number: _________________ Place of Birth: ___________________ Date of Birth: __________
4. Resident Address: ______________________________________________________________________________
Street
City
State
Zip Code
5. Last address in U.S.: ____________________________________________________________________________
Street
City
State
Zip Code
I, the undersigned, for and on behalf of the insurance company, whose name appears upon, do hereby certify that the
individual for whom a license/appointment is requested, has been thoroughly investigated as to integrity and character;
that he has the necessary training to hold himself out as a life insurance representative; and this company is willing to be
bound by the acts of such applicant within the scope of his employment.
Life Insurance Company Name: ____________________________________________, Company Code: __________
Home Office Address (FL): __________________________________________________________________________
Street
City
State
Zip Code
Mailing Address in Foreign Country (For ALL of your correspondence):
______________________________________________________________________________________________
Sworn to and subscribed before me this _____ day of
_______________, 20_____
_____________________________________________
Company Official (Print/Sign)
_____________________________________________
______________________________________________
Title
Date
Notary Public (Print/Sign)
______________________________________________
City
State
Mail Completed Form to:
(Print, Type, or Stamp Commissioned Name of Notary)
Revenue Processing Section
P.O. Box 6000
Personally Known OR
Produced Identification
Tallahassee, FL 32314-6000
Type of Identification Produced: ___________________
My Commission Expires: _________________________
FEES ARE NON-REFUNDABLE
(SEAL)
Application for License-Filling Fee
$ 50 0093 (F)
I.D. License Fee
$ 5 0090 (F)
Appointment Fee
$ 20 0093 (L)
TOTAL FEES ENCLOSED:
$_____________
Page 1 of 2
DFS-H2-376
Rule 69B-211.002, F.A.C.
Revision 03/17
F
D
F
S
LORIDA
EPARTMENT OF
INANCIAL
ERVICES
Division of Insurance Agent and Agency Services – Bureau of Licensing
Privacy Statement
Pursuant to the Privacy Act of 1974, 5 U.S.C. § 552a, the State is responsible for informing you whether
disclosure of your social security number is mandatory or voluntary, by what statutory or other authority your
social security number is solicited, and what uses will be made of your social security number. Under §
119.071(5)(a)2.a., F.S., a state agency may collect your social security number if the collection is:
(I) specifically authorized by law; or
(II) imperative for the performance of the agency’s duties and responsibilities as prescribed by law.
Disclosure of your social security number on this form is mandatory pursuant to the Welfare Reform Act, 42
U.S.C. § 666, and §§ 626.171(2)(a) and (7), 626.231(2)(a), 626.541(1), and 626.9953(3)(a) and (7), F.S.
The purposes for the requested information are to verify the identity of an applicant for licensure, to conduct
criminal and disciplinary history background checks, and to determine if the applicant lacks the fitness or
trustworthiness to engage in the business of insurance. Your social security number is confidential and exempt
from the disclosure requirements of § 119.07(1), F.S., and § 24(a), Article I of the Florida Constitution and will
not be used for any purpose other than the purposes provided herein, or as otherwise authorized under §
119.071(5)(a), F.S.
A copy of this Privacy Statement is provided to you as required by § 119.071(5)(a)3., F.S.
Page 2 of 2
DFS-H2-376
Rule 69B-211.002, F.A.C.
Revision 03/17
Page of 2