Form DFS-H2-1783 "Neutral Evaluator Application" - Florida

What Is Form DFS-H2-1783?

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 printable version of Form DFS-H2-1783 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-H2-1783 "Neutral Evaluator Application" - Florida

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DEPARTMENT OF FINANCIAL SERVICES
Division of Insurance Agent and Agency Services – Bureau of Licensing
200 East Gaines Street, Larson Building, Room 419
Tallahassee, FL 32399-0319
Neutral Evaluator Application
License Type and Class 00-57
(Please Type)
Last Name
First Name
Middle Initial
Social Security Number
Date of Birth
Sex
Are you a US citizen?
Yes / No
Place of Birth
Home Street Address
Apt. #
Home City
State
Home Zip Code
Business Street Address
Bldg #
Business City
State
Business Zip Code
Mailing Street Address
Bldg #
Mailing City
State
Mailing Zip Code
Home Telephone Number
Work Telephone Number
Email Address
I affirm that I understand I must maintain a valid email address on file with the Department.
Yes / No
Current employment:
Beginning Date
Name of Employer
Street Address
City
State
Zip Code
DFS-H2-1783
Revised 03/17
Rule 69B-251.003, F.A.C.
Page 1 of 3
DEPARTMENT OF FINANCIAL SERVICES
Division of Insurance Agent and Agency Services – Bureau of Licensing
200 East Gaines Street, Larson Building, Room 419
Tallahassee, FL 32399-0319
Neutral Evaluator Application
License Type and Class 00-57
(Please Type)
Last Name
First Name
Middle Initial
Social Security Number
Date of Birth
Sex
Are you a US citizen?
Yes / No
Place of Birth
Home Street Address
Apt. #
Home City
State
Home Zip Code
Business Street Address
Bldg #
Business City
State
Business Zip Code
Mailing Street Address
Bldg #
Mailing City
State
Mailing Zip Code
Home Telephone Number
Work Telephone Number
Email Address
I affirm that I understand I must maintain a valid email address on file with the Department.
Yes / No
Current employment:
Beginning Date
Name of Employer
Street Address
City
State
Zip Code
DFS-H2-1783
Revised 03/17
Rule 69B-251.003, F.A.C.
Page 1 of 3
BACKGROUND QUESTIONS
If you have EVER entered a plea of guilty, nolo contendere (no contest), or been convicted or found guilty of a felony
crime, you are required to give a "Yes" answer, whether or not adjudication of guilt was withheld. If you have been so
convicted or have entered one of the pleas above and fail to provide a "Yes" answer, your application may be
denied. If you are unsure about how to answer questions regarding your criminal history, you should consult an
attorney or review your court records prior to answering.
If you have additional questions, please contact the Bureau of Licensing at 850-413-3137.
Are you currently on probation for any legal action or participating in a pretrial intervention program
Yes / No
or any other diversion program?
Are there currently pending against you or any entity you control, any criminal, administrative
(including those by the Financial Industry Regulatory Authority (“FINRA”)) or civil charges in any
Yes / No
state or federal court anywhere in the United States or its possessions or any other country?
In the past 12 months, have you been arrested, indicted, or had an Information filed against you or
been otherwise charged with a crime by any law enforcement authority anywhere in the United
Yes / No
States or its possessions or any other country?
Have you ever been convicted, found guilty, or pled guilty or nolo contendere (no contest) to a
felony under the laws of any municipality, county, state, territory or country, whether or not
Yes / No
adjudication was withheld or a judgment of conviction was entered?
Have you ever been refused a securities, real estate broker, or other license by a state agency or a
Yes / No
public authority in any jurisdiction?
Have you ever had an application for a license declined or denied by this or any other insurance
Yes / No
regulatory body (including FINRA)?
Have you ever been named in an administrative proceeding/action by any state agency or public
authority or any other regulatory authority (including FINRA)? (This would include fines, probation,
Yes / No
restitution, restricted or probationary licenses, cease and desist orders, suspension, revocation, or
denial.)
Are you currently indebted to any insurer, managing general agent, agent, or premium finance
Yes / No
company?
Have you failed to comply with any civil, criminal, or administrative action taken by a child support
enforcement program under Title IV-D of the Social Security Act, 42 U.S.C. ss. 651 et seq., to
Yes / No
determine paternity or to establish, modify, enforce, or collect support?
REQUIREMENTS FOR QUALIFYING
ENGINEER:
Are you currently licensed as an Engineer with the Florida Department of Business and Professional
Yes / No
Regulation (DBPR)?
If Yes, what is your license number?
This license number will be verified with DBPR.
GEOLOGIST:
Are you currently licensed as a Professional Geologist with the Florida Department of Business and
Yes / No
Professional Regulation (DBPR)?
If Yes, what is your license number?
This license number will be verified with DBPR.
ADR TRAINING:
Have you completed a course of study in alternative dispute resolution (ADR) that has been
Yes / No
approved by the Florida Department of Financial Services for use in the neutral evaluation process?
If Yes, what was the date of completion?
Attach a copy of the certification or proof of course completion with this application.
BUSINESS AFFLIATIONS:
Do you understand that you cannot be employed by a property insurer, property insurance adjuster,
public adjuster, or adjusting firm while certified by the Florida Department of Financial Services as a
Yes / No
neutral evaluator?
DFS-H2-1783
Revised 03/17
Rule 69B-251.003, F.A.C.
Page 2 of 3
I DO SOLEMNLY SWEAR THAT ALL ANSWERS TO THE FOREGOING QUESTIONS ARE TRUE AND CORRECT
TO THE BEST OF MY KNOWLEDGE AND BELIEF; THAT I UNDERSTAND THE LAWS OF FLORIDA AND THE
RULES PROMULGATED BY THE CHIEF FINANCIAL OFFICER REGULATING THE EVALUATION OF CLAIMS
PURSUANT TO SECTIONS 627.706 AND 627.7074, F.S.
I AFFIRM I AM AN ENGINEER LICENSED UNDER CHAPTER 471, F.S., OR A GEOLOGIST LICENSED UNDER
CHAPTER 492, F.S., WHO HAS EXPERIENCE AND EXPERTISE IN THE IDENTIFICATION OF SINKHOLE
ACTIVITY AS WELL AS OTHER POTENTIAL CAUSES OF STRUCTURAL DAMAGE.
WHOEVER KNOWINGLY MAKES A FALSE STATEMENT IN WRITING WITH THE INTENT TO MISLEAD A
PUBLIC SERVANT IN THE PERFORMANCE OF HIS/HER OFFICIAL DUTY SHALL BE GUILTY OF A
MISDEMEANOR OF THE SECOND DEGREE.
UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING NEUTRAL EVALUATOR
APPLICATION AND THAT THE FACTS STATED IN IT ARE TRUE.
Signature of Applicant
Date
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 voluntary and imperative for the performance of the agency’s
duties and responsibilities under § 119.071(5)(a)2.a.(II), § 627.706, and § 627.7074, F.S.
The purposes for the requested information are to verify the identity and qualifications of an applicant for certification, to
conduct criminal and disciplinary history background checks, and to determine if the applicant lacks the fitness or
trustworthiness to act as a neutral evaluator. 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-H2-1783
Revised 03/17
Rule 69B-251.003, F.A.C.
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