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

What Is Form DFS-H2-569?

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 September 1, 1995;
  • 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 fillable version of Form DFS-H2-569 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-H2-569 "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.