Form DFS-H2-6364 "Designation/Deletion of Primary Adjuster for Adjusting Firm and Filing of Firm, Corporation, or Business Name Change" - Florida

What Is Form DFS-H2-6364?

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 September 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-H2-6364 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-H2-6364 "Designation/Deletion of Primary Adjuster for Adjusting Firm and Filing of Firm, Corporation, or Business Name Change" - Florida

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FLORIDA DEPARTMENT OF FINANCIAL SERVICES
Division of Insurance Agent & Agency Services
200 East Gaines Street
Tallahassee, FL 32399-0319
DESIGNATION/DELETION OF PRIMARY ADJUSTER FOR ADJUSTING FIRM
And FILING OF FIRM, CORPORATION, OR BUSINESS NAME CHANGE
This form must be filed with the Department of Financial Services within 30 days of the adjusting firm inception or change of
primary adjuster designation, pursuant to 626.8695, Florida Statutes. NOTE: If changes occur regarding item #5 on the
REVERSE SIDE, SUCH CHANGES MUST BE FILED, USING THIS FORM, WITH the department within 30 days.
NOTE:
THIS FORM WILL NOT UPDATE THE ADDRESS OF ANY INDIVIDUAL ADJUSTER; IT ONLY UPDATES THE
ADDRESS OF THE NAMED ADJUSTING FIRM.
1.
Owner’s full name, Florida License Number, and resident addresses if not an incorporated agency or firm:
________________________________________________
__________________________________________________________
Florida License Number
Owner's Email Address
Owner's Name
Resident Telephone Number
__________________________________________________________________________________________________________________________
Resident Street Address
City
State
Zip Code
2.
Business Name, Federal ID number, street address, email and telephone number of the adjusting firm:
________________________________________________
_____________________________________________________________
Federal ID Number
Adjusting Firm's Email Address
Business Name
Business Telephone Number
__________________________________________________________________________________________________________________________
Business Street Address
City
State
Zip Code
3.
Full name, email address, and Florida License Number of the individual who is the designated or deleted Primary Adjuster
for the adjusting firm location given in section 2. (See instructions below)
Designate
Delete
Florida License Number
Primary Adjuster’s Email Address
Name
DFS-H2-6364
Revised 09/17
Page 1 of 3
Print Form
FLORIDA DEPARTMENT OF FINANCIAL SERVICES
Division of Insurance Agent & Agency Services
200 East Gaines Street
Tallahassee, FL 32399-0319
DESIGNATION/DELETION OF PRIMARY ADJUSTER FOR ADJUSTING FIRM
And FILING OF FIRM, CORPORATION, OR BUSINESS NAME CHANGE
This form must be filed with the Department of Financial Services within 30 days of the adjusting firm inception or change of
primary adjuster designation, pursuant to 626.8695, Florida Statutes. NOTE: If changes occur regarding item #5 on the
REVERSE SIDE, SUCH CHANGES MUST BE FILED, USING THIS FORM, WITH the department within 30 days.
NOTE:
THIS FORM WILL NOT UPDATE THE ADDRESS OF ANY INDIVIDUAL ADJUSTER; IT ONLY UPDATES THE
ADDRESS OF THE NAMED ADJUSTING FIRM.
1.
Owner’s full name, Florida License Number, and resident addresses if not an incorporated agency or firm:
________________________________________________
__________________________________________________________
Florida License Number
Owner's Email Address
Owner's Name
Resident Telephone Number
__________________________________________________________________________________________________________________________
Resident Street Address
City
State
Zip Code
2.
Business Name, Federal ID number, street address, email and telephone number of the adjusting firm:
________________________________________________
_____________________________________________________________
Federal ID Number
Adjusting Firm's Email Address
Business Name
Business Telephone Number
__________________________________________________________________________________________________________________________
Business Street Address
City
State
Zip Code
3.
Full name, email address, and Florida License Number of the individual who is the designated or deleted Primary Adjuster
for the adjusting firm location given in section 2. (See instructions below)
Designate
Delete
Florida License Number
Primary Adjuster’s Email Address
Name
DFS-H2-6364
Revised 09/17
Page 1 of 3
4.
Are there additional business locations operating under the same business name given in section 2?
Yes
No.
If “Yes” is marked, list the complete address for each of the additional locations. (Attach additional page if needed.)
Business Street Address
City
State
Zip Code
Business Street Address
City
State
Zip Code
5.
Name and Florida License Number of the president, directors and other persons associated under the firm or corporate
name listed in section 2 that are involved in adjusting or use of the business name:
Florida License Number
Name
Email Address
Florida License Number
Name
Email Address
Florida License Number
Name
Email Address
I understand that if there is a change in the above information, that I must complete a new form and file it with the Department
of Financial Services within thirty (30) days.
_
Signature of Primary Adjuster
Date
T
:
HIS FORM MAY BE FILED BY
Email:
Adjusters@MyFloridaCFO.com
Division of Insurance Agent & Agency Services  Bureau of Investigation
Mail:
200 East Gaines Street  Larson Building #412  Tallahassee, FL 32399-0320
Fax:
(850) 488-5951
DFS-H2-6364
Revised 09/17
Page 2 of 3
I
NSTRUCTIONS
Do NOT send this page
SPECIAL NOTE TO THE DESIGNATED PRIMARY ADJUSTER
When an updated form is filed designating another primary adjuster, the previous designee will no longer be considered the
current primary adjuster for that designated location. If you should leave the adjusting firm you will still be considered the
primary adjuster until the adjusting firm files a new form. If you will no longer be working at the adjusting firm location as the
designated primary adjuster, you are advised to submit this form with item numbers two and three completed and the
appropriate delete box checked with your signature in the space provided. Failure to remove yourself as the primary
adjuster may result in you continuing to be held responsible for the activities of the adjusting firm until a new designation is
made.
INSTRUCTIONS FOR COMPLETING PRIMARY AGENT/PRIMARY ADJUSTER FORM
To be completed by each person operating an adjusting firm and for each location of multiple adjusting firm (See definitions
of adjusting firm shown below).
Each business location established by an adjuster, an adjusting firm, a corporation, or an association must designate with
the department a primary adjuster who is licensed and appointed to adjust the insurance claims adjusted by the business
location. The primary adjuster may be the same person listed in section 1. If the adjusting firm listed in section 2 is not a
corporation, then use the social security number of the individual owner in place of the Federal ID (See definitions of primary
adjuster shown below).
One form is required for each designation or deletion. The same form CANNOT be used for both. The signature of the
primary adjuster is required for each adjusting firm location in order for the designation or deletion to be valid.
DEFINITIONS
Section 626.8695(3), Florida Statutes: Primary Adjuster is the licensed adjuster who is responsible for the supervision of all
individuals within an adjusting firm location who act in the capacity of an adjuster. Note: An adjuster may be designated as
a primary adjuster for more than only one adjusting firm location provided no person engages in activity requiring licensure
as an adjuster at any location when an adjuster is not physically present.
Section 626.8695(4), Florida Statutes: An Adjusting Firm is a location where an independent or public adjuster is engaged
in the business of insurance.
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., F.S., a state agency
may collect your social security number if the collection is specifically authorized by law or if it is 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.
DFS-H2-6364
Revised 09/17
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