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

This version of the form is not currently in use and is provided for reference only.
Download this version of Form DFS-H2-1428 for the current year.

What Is Form DFS-H2-1428?

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 April 1, 2016;
  • 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;

Download a fillable version of Form DFS-H2-1428 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-H2-1428 "Agent Qualification and Verification of Experience Form - Surplus Lines" - Florida

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DEPARTMENT OF FINANCIAL SERVICES
Division of Agent & Agency Services – Bureau of Licensing
200 East Gaines Street, Larson Building Room 419
Tallahassee, FL 32399-0319
AGENT QUALIFICATION AND VERIFICATION OF EXPERIENCE FORM
SURPLUS LINES QUALIFICATIONS STATEMENT
Experience – One Year
I certify that I have had one (1) year of responsible duties within the past four (4) years as a substantially full time bona
fide employee of surplus lines insurance. I further certify that I understand I must also be licensed and appointed as a
Florida general lines agent in order to qualify to take the surplus lines examination.
Note: You must attach a typed statement with a detailed account of your experience.
________
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
*NOTE
You are required by state and federal law to disclose your social security number on this application. Section 666(a)(13)
of Title 42, Unites States Code, requires each state to obtain the social security number of each applicant for a
professional or occupational license on the application for the license. Section 626.171(5), Florida Statutes, implements
this federal law. The purpose of collecting social security numbers is for administration of the child support enforcement
provisions of Title IV-D of the Social Security Act. The Department of Financial Services also uses social security
numbers for identity verification purposes in conjunction with background checks of applicants and for identity
verification purposes in the Department's electronic database for licensees and applicants.
DFS-H2-1428
Revision 04/16
DEPARTMENT OF FINANCIAL SERVICES
Division of Agent & Agency Services – Bureau of Licensing
200 East Gaines Street, Larson Building Room 419
Tallahassee, FL 32399-0319
AGENT QUALIFICATION AND VERIFICATION OF EXPERIENCE FORM
SURPLUS LINES QUALIFICATIONS STATEMENT
Experience – One Year
I certify that I have had one (1) year of responsible duties within the past four (4) years as a substantially full time bona
fide employee of surplus lines insurance. I further certify that I understand I must also be licensed and appointed as a
Florida general lines agent in order to qualify to take the surplus lines examination.
Note: You must attach a typed statement with a detailed account of your experience.
________
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
*NOTE
You are required by state and federal law to disclose your social security number on this application. Section 666(a)(13)
of Title 42, Unites States Code, requires each state to obtain the social security number of each applicant for a
professional or occupational license on the application for the license. Section 626.171(5), Florida Statutes, implements
this federal law. The purpose of collecting social security numbers is for administration of the child support enforcement
provisions of Title IV-D of the Social Security Act. The Department of Financial Services also uses social security
numbers for identity verification purposes in conjunction with background checks of applicants and for identity
verification purposes in the Department's electronic database for licensees and applicants.
DFS-H2-1428
Revision 04/16