Form DFS-H2-1109 "Application for Clu/Cpcu/College Degree + Experience Status" - Florida

What Is Form DFS-H2-1109?

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 December 1, 2005;
  • 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-H2-1109 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-H2-1109 "Application for Clu/Cpcu/College Degree + Experience Status" - Florida

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DEPARTMENT OF FINANCIAL SERVICES
Division of Agent & Agency Services – Bureau of Licensing
200 East Gaines Street, Larson Building,
Tallahassee, FL 32399-0319
Education Section
APPLICATION FOR CLU/CPCU/COLLEGE DEGREE + EXPERIENCE STATUS
To qualify for a reduction in your continuing education requirement you must complete this form and return it to the address above the
required documentation. A certifying individual other than the applicant must complete the statement of experience. Documentation
of designation or degree must be attached as well as proof of experience as a licensed agent if experience was obtained outside of
Florida.
Applicant Name:
Applicant License #:
To be eligible for continuing education reduction, the applicant must have:
1. A CLU or CPCU designation with 25 years of experience as a licensed agent in the same line of business as the designation,
i.e., 25 years experience as a life and health agent and CLU designation or;
2. A college degree in Risk Management or insurance with at least 18 semester hours of approved insurance courses and 25
years of experience as a licensed agent in the same line of business as the license.
This form must be submitted with all written documentation prior to the applicant’s birth month in the year in which
compliance for continuing education is due to be considered for the credit.
___________________________________________
Signature of Applicant
Date Signed
Statement of Experience – This must be completed by a certifying individual other than the applicant.
I certify that the applicant above is known to me and I have known him/her to be a licensed agent in the State of Florida for
years.
I certify that the applicant above is known to me and that I have known him/her to be a licensed agent in the State of
, for
years.
_________________________________________
Type or Print Certifying Individual’s Name
Signature of Certifying Individual
Business Name of Certifying Individual
Date Signed
-
-
\
Telephone Number of Certifying Individual
NOTE: If you lose your CLU or CPCU designation, you are required to notify the Department. Loss of designation or authority will
invalidate the reduction in CE requirement.
DFS-H2-1109
Revised 12/05
Print Form
DEPARTMENT OF FINANCIAL SERVICES
Division of Agent & Agency Services – Bureau of Licensing
200 East Gaines Street, Larson Building,
Tallahassee, FL 32399-0319
Education Section
APPLICATION FOR CLU/CPCU/COLLEGE DEGREE + EXPERIENCE STATUS
To qualify for a reduction in your continuing education requirement you must complete this form and return it to the address above the
required documentation. A certifying individual other than the applicant must complete the statement of experience. Documentation
of designation or degree must be attached as well as proof of experience as a licensed agent if experience was obtained outside of
Florida.
Applicant Name:
Applicant License #:
To be eligible for continuing education reduction, the applicant must have:
1. A CLU or CPCU designation with 25 years of experience as a licensed agent in the same line of business as the designation,
i.e., 25 years experience as a life and health agent and CLU designation or;
2. A college degree in Risk Management or insurance with at least 18 semester hours of approved insurance courses and 25
years of experience as a licensed agent in the same line of business as the license.
This form must be submitted with all written documentation prior to the applicant’s birth month in the year in which
compliance for continuing education is due to be considered for the credit.
___________________________________________
Signature of Applicant
Date Signed
Statement of Experience – This must be completed by a certifying individual other than the applicant.
I certify that the applicant above is known to me and I have known him/her to be a licensed agent in the State of Florida for
years.
I certify that the applicant above is known to me and that I have known him/her to be a licensed agent in the State of
, for
years.
_________________________________________
Type or Print Certifying Individual’s Name
Signature of Certifying Individual
Business Name of Certifying Individual
Date Signed
-
-
\
Telephone Number of Certifying Individual
NOTE: If you lose your CLU or CPCU designation, you are required to notify the Department. Loss of designation or authority will
invalidate the reduction in CE requirement.
DFS-H2-1109
Revised 12/05