Form DFS-H2-591 "Mediator Application" - Florida

Form DFS-H2-591 or the "Mediator Application" is a form issued by the Florida Department of Financial Services.

Download a PDF version of the Form DFS-H2-591 down below or find it on the Florida Department of Financial Services Forms website.

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Download Form DFS-H2-591 "Mediator 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
MEDIATOR APPLICATION
License Type and Class 00-56
(Please Type)
Last Name
First Name
Middle Initial
Social Security Number
Date of Birth
Sex
Place of Birth
State
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-H2-591
Revised 03/17
Rule 69B-250.002, F.A.C.
Page 1 of 4
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
MEDIATOR APPLICATION
License Type and Class 00-56
(Please Type)
Last Name
First Name
Middle Initial
Social Security Number
Date of Birth
Sex
Place of Birth
State
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-H2-591
Revised 03/17
Rule 69B-250.002, F.A.C.
Page 1 of 4
Are you currently affiliated with any mediation services?
Yes / No
If YES, list the name, location, and position held with each mediation panel or provider:
Name
Address, City, State
Position
Indicate each county in which you will conduct mediation for the standard mediation fee for this program, with no
additional charges for costs or expenses:
01
Dade
20
St. Johns
39
Levy
58
Calhoun
02
Duval
21
Gadsden
40
Hernando
59
Franklin
03
Hillsborough
22
Putnam
41
Nassau
60
Glades
04
Pinellas
23
Bay
42
Martin
61
Flagler
05
Polk
24
St. Lucie
43
Okaloosa
62
Lafayette
06
Palm Beach
25
Jackson
44
Sumter
63
Union
07
Orange
26
Osceola
45
Bradford
64
Collier
08
Volusia
27
Highlands
46
Jefferson
65
Wakulla
09
Escambia
28
Pasco
47
Citrus
66
Gulf
10
Broward
29
Columbia
48
Clay
67
Liberty
11
Alachua
30
Hardee
49
Hendry
STATEWIDE
12
Lake
31
Suwannee
50
Washington
13
Leon
32
Indian River
51
Holms
14
Marion
33
Santa Rosa
52
Baker
15
Manatee
34
De Soto
53
Charlotte
16
Sarasota
35
Madison
54
Dixie
17
Seminole
36
Walton
55
Gilchrist
18
Lee
37
Taylor
56
Hamilton
19
Brevard
38
Monroe
57
Okeechobee
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?
DFS-H2-591
Revised 03/17
Rule 69B-250.002, F.A.C.
Page 2 of 4
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?
Have you ever been subject to any civil, criminal, or administrative action for a violation of any
provision of the Florida Insurance Code, or of a lawful order or rule of the Department, violation of
Yes / No
the Florida Rules for Certified and Court-Appointed Mediators, or aiding, instructing, or encouraging
another party in committing such a violation?
REQUIREMENTS FOR QUALIFYING
Do you possess an active certification as a Florida Supreme Court certified circuit court mediator?
Note: A Florida Supreme Court certified circuit court mediator in a lapsed, suspended, sanctioned,
Yes / No
or decertified status is not eligible to participate in the mediation program. Certification as a County,
Family, or Dependency mediator type does not qualify.
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 MEDIATION OF CLAIMS
PURSUANT TO SECTIONS 627.745 AND 627.7015, F.S.
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 MEDIATOR
APPLICATION AND THAT THE FACTS STATED IN IT ARE TRUE.
Signature of Applicant
Date
DFS-H2-591
Revised 03/17
Rule 69B-250.002, F.A.C.
Page 3 of 4
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), § 627.745 and § 627.7015, F.S.
The purposes for the requested information are to verify the identity and qualifications of an applicant, to conduct criminal
and disciplinary history background checks, and to determine if the applicant lacks the fitness or trustworthiness to act as
a mediator. 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-H2-591
Revised 03/17
Rule 69B-250.002, F.A.C.
Page 4 of 4
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