Form DFS-H2-1428 "Agent Qualification and Verification of Experience Form - Personal Lines" - Florida

Form DFS-H2-1428 is a Florida Department of Financial Services form also known as the "Agent Qualification And Verification Of Experience Form - Personal Lines". The latest edition of the form was released in October 1, 2017 and is available for digital filing.

Download a PDF version of the Form DFS-H2-1428 down below or find it on Florida Department of Financial Services Forms website.

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Download Form DFS-H2-1428 "Agent Qualification and Verification of Experience Form - Personal Lines" - Florida

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DEPARTMENT OF FINANCIAL SERVICES
Division of Agent and Agency Services – Bureau of Licensing
200 East Gaines Street, Larson Building Room 419
Tallahassee, FL 32399-0319
AGENT QUALIFICATION AND VERIFICATION OF EXPERIENCE FORM
PERSONAL LINES QUALIFICATIONS STATEMENT
Check one and initial:
Six Months of Experience
I certify that I have six (6) months of responsible duties within the past four (4) years as a substantially full time bona fide
employee in the area of property and casualty insurance AND have sold to individuals and families for noncommercial
purposes.
INITIALS
Six Months Licensed and Appointed
I certify that I have six (6) months of responsible duties within the past four (4) years as a licensed and appointed
4-40 customer representative, 04-42 limited customer representative, or 0-55 service representative lines agent.
INITIALS
EMPLOYER CERTIFICATION
As applicant’s current or prior employer, I certify that the applicant has completed the above experience qualification, and that
compensation did/did not include, in whole or any part, any commissions and was not primarily based in the production of
applications, insurance or premiums, except in cases where the applicant may have been properly licensed in this or another
state and therefore, authorized to receive such compensation. I further certify that this applicant has not transacted business in
violation of the Florida Statutes.
By signature of this form, applicant/employer declares, under penalty of perjury, that the foregoing statements and facts stated
herein are true and correct:
Applicant Signature
Employer Signature
Print Applicant Name
Print Employer Name
Applicant’s Social Security Number
Agency Name
Agency Address
City
State
Zip
DFS-H2-1428
Revision 10/17
DEPARTMENT OF FINANCIAL SERVICES
Division of Agent and Agency Services – Bureau of Licensing
200 East Gaines Street, Larson Building Room 419
Tallahassee, FL 32399-0319
AGENT QUALIFICATION AND VERIFICATION OF EXPERIENCE FORM
PERSONAL LINES QUALIFICATIONS STATEMENT
Check one and initial:
Six Months of Experience
I certify that I have six (6) months of responsible duties within the past four (4) years as a substantially full time bona fide
employee in the area of property and casualty insurance AND have sold to individuals and families for noncommercial
purposes.
INITIALS
Six Months Licensed and Appointed
I certify that I have six (6) months of responsible duties within the past four (4) years as a licensed and appointed
4-40 customer representative, 04-42 limited customer representative, or 0-55 service representative lines agent.
INITIALS
EMPLOYER CERTIFICATION
As applicant’s current or prior employer, I certify that the applicant has completed the above experience qualification, and that
compensation did/did not include, in whole or any part, any commissions and was not primarily based in the production of
applications, insurance or premiums, except in cases where the applicant may have been properly licensed in this or another
state and therefore, authorized to receive such compensation. I further certify that this applicant has not transacted business in
violation of the Florida Statutes.
By signature of this form, applicant/employer declares, under penalty of perjury, that the foregoing statements and facts stated
herein are true and correct:
Applicant Signature
Employer Signature
Print Applicant Name
Print Employer Name
Applicant’s Social Security Number
Agency Name
Agency Address
City
State
Zip
DFS-H2-1428
Revision 10/17
DEPARTMENT OF FINANCIAL SERVICES
Division of Agent and Agency Services – Bureau of Licensing
200 East Gaines Street, Larson Building Room 419
Tallahassee, FL 32399-0319
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.
DFS-H2-1428
Revision 10/17
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