Form DFS-H2-569 "Registration of Fraternal Benefit Society Representatives" - Florida

Form DFS-H2-569 is a Florida Department of Financial Services form also known as the "Registration Of Fraternal Benefit Society Representatives". The latest edition of the form was released in September 1, 1995 and is available for digital filing.

Download a PDF version of the Form DFS-H2-569 down below or find it on Florida Department of Financial Services Forms website.

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Download Form DFS-H2-569 "Registration of Fraternal Benefit Society Representatives" - 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
REGISTRATION OF FRATERNAL BENEFIT SOCIETY REPRESENTATIVES
During the preceding calendar year, pursuant to Section 632.634 (3), F.S., the following solicited
and procured life insurance benefit contracts in a total amount of insurance of less than $50,000 or
have written any kind or kinds of insurance benefit contracts our society writes on not more than 25
individuals.
NAME OF INDIVIDUAL
RESIDENCE ADDRESS
Name of Fraternal Benefit Society
Address
Authorized Signature and Title
Date
DFS-H2-569
Revised 09/95
Rule 69B-211.002, F.A.C.
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
REGISTRATION OF FRATERNAL BENEFIT SOCIETY REPRESENTATIVES
During the preceding calendar year, pursuant to Section 632.634 (3), F.S., the following solicited
and procured life insurance benefit contracts in a total amount of insurance of less than $50,000 or
have written any kind or kinds of insurance benefit contracts our society writes on not more than 25
individuals.
NAME OF INDIVIDUAL
RESIDENCE ADDRESS
Name of Fraternal Benefit Society
Address
Authorized Signature and Title
Date
DFS-H2-569
Revised 09/95
Rule 69B-211.002, F.A.C.
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