Form DFS-H2-1124 "Designation or Deletion of Supervising Agent for Customer Representatives and Limited Customer Representatives" - Florida

Form DFS-H2-1124 or the "Designation Or Deletion Of Supervising Agent For Customer Representatives And Limited Customer Representatives" is a form issued by the Florida Department of Financial Services.

The form was last revised in March 1, 2015 and is available for digital filing. Download an up-to-date Form DFS-H2-1124 in PDF-format down below or look it up on the Florida Department of Financial Services Forms website.

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Download Form DFS-H2-1124 "Designation or Deletion of Supervising Agent for Customer Representatives and Limited Customer Representatives" - Florida

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DEPARTMENT OF FINANCIAL SERVICES
Division of Agent & Agency Services – Bureau of Licensing
200 East Gaines Street, Tallahassee, FL 32399-0319
Email:
AgentLicensing@MyFloridaCFO.com
Fax: (850) 413-3291
Designation or Deletion Of Supervising Agent For
Customer Representatives And Limited Customer Representatives
This form does not update the demographics of any licensee.
This form must be completed at the inception or termination of supervision of a Customer Representative or a
Limited Customer Representative by the supervising licensed and appointed general lines agent and sent to the
department at one of the addresses above.
1. Licensed / Registered Agency Information
Agency License/
Registration Number:
Agency Name
Address of Agency:
2. Supervising Agent Information:
License Number:
Agent Name
3. Customer Representatives supervised by agent listed above:
To Be
No Longer
Representative’s Name
License Number:
Supervised
Supervised
Note:
Customer Representatives & Limited Customer Representatives are appointed through the MyProfile website, only.
I understand and agree to supervise the activities of the customer representatives listed above.
I understand that if there is a change in the above information, I must complete a new form and submit it to the
Department of Financial Services within ten (10) calendar days of the change being effective and I should retain a
complete and accurate copy of this form in the agency records as listed in number 1 above.
Supervising Agent’s Signature
Supervising Agent’s Printed Name
Date
DFS-H2-1124
Revised 03/15
69B-213.060, F.A.C.
DEPARTMENT OF FINANCIAL SERVICES
Division of Agent & Agency Services – Bureau of Licensing
200 East Gaines Street, Tallahassee, FL 32399-0319
Email:
AgentLicensing@MyFloridaCFO.com
Fax: (850) 413-3291
Designation or Deletion Of Supervising Agent For
Customer Representatives And Limited Customer Representatives
This form does not update the demographics of any licensee.
This form must be completed at the inception or termination of supervision of a Customer Representative or a
Limited Customer Representative by the supervising licensed and appointed general lines agent and sent to the
department at one of the addresses above.
1. Licensed / Registered Agency Information
Agency License/
Registration Number:
Agency Name
Address of Agency:
2. Supervising Agent Information:
License Number:
Agent Name
3. Customer Representatives supervised by agent listed above:
To Be
No Longer
Representative’s Name
License Number:
Supervised
Supervised
Note:
Customer Representatives & Limited Customer Representatives are appointed through the MyProfile website, only.
I understand and agree to supervise the activities of the customer representatives listed above.
I understand that if there is a change in the above information, I must complete a new form and submit it to the
Department of Financial Services within ten (10) calendar days of the change being effective and I should retain a
complete and accurate copy of this form in the agency records as listed in number 1 above.
Supervising Agent’s Signature
Supervising Agent’s Printed Name
Date
DFS-H2-1124
Revised 03/15
69B-213.060, F.A.C.
Instructions for Completing the Designation Of Supervising Agent For
Customer Representatives And Limited Customer Representatives Form
This form is to be completed by the licensed and appointed general lines insurance agent within the
insurance agency who is supervising at least one customer representative or limited customer
representative working in that agency.
The supervising agent, designated supervising agent, customer representative and limited customer
representative listed on this form are required to adhere to the provisions of chapter 69B-213, Florida
Administrative Code, which describes the process of designating a supervising agent and appointing a
customer representative or limited customer representative.
Identifying information about the agency where the supervising agent and customer representative
Section 1:
have been or will be working.
Identifying information about the licensed and appointed agent designated as the supervising agent
Section 2:
for the licensees in Section 3.
Identifying information of the customer representatives or limited customer representatives who are
Section 3:
supervised by the agent listed in Section 2.
If this form is being used to designate a supervising agent, then the box under “To Be Supervised”
must be checked.
If the agent no longer supervises the licensee listed, then the box under “No Longer Supervised” must
be checked.
This form must be signed by the licensed and appointed agent who is accepting or terminating the role of
supervising the customer representative or limited customer representative.
“Customer Representative”
means an individual appointed by a general lines agent or general
Definitions:
lines agency to assist that agent or agency in transacting the business of insurance from the office of
that agent or agency.
“Limited Customer Representative”
means an individual appointed by a general lines agent or
agency to assist in transacting only the business of private passenger motor vehicle insurance from
the office of that agent or agency. A limited customer representative is subject to the Florida
Insurance Code in the same manner as a customer representative, unless otherwise specified.
“Insurance Agency”
is a location where any agent is engaged in the business of insurance.
“Supervising agent”
includes both:
•the appointing agent in instances where a customer representative is appointed by an agent, or
•an agent designated by an agency to supervise a customer representative in instances where
an agency appoints a customer representative.
“Designated supervising agent”
means a general lines agent designated by an agency to supervise
the customer representative or customer representatives the agency has appointed.
You must submit the completed form to the Department of Financial Services at
Reminder:
the address shown on the form.
Customer Representatives & Limited Customer Representatives are appointed
through the MyProfile section of the department’s website:
https://dice.fldfs.com
DFS-H2-1124
Revised 03/15
69B-213.060, F.A.C.
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