Form FIS2312 "Limited Power of Attorney" - Michigan

What Is Form FIS2312?

This is a legal form that was released by the Michigan Department of Insurance and Financial Services - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2016;
  • The latest edition provided by the Michigan Department of Insurance and 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 FIS2312 by clicking the link below or browse more documents and templates provided by the Michigan Department of Insurance and Financial Services.

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Download Form FIS2312 "Limited Power of Attorney" - Michigan

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FIS 2312 (4/16) Department of Insurance and Financial Services Page 1 of 2
Issued under authority of Public Act 218 of 1956.
Limited Power of Attorney
INSTRUCTIONS: Use this form to authorize the Michigan Department of Insurance and Financial Services to communicate with a
named individual or entity acting on your behalf. If you choose (see Part 4), such communications will include the disclosure of
confidential information related to your license application.
PART 1: APPLICANT INFORMATION
Applicant's Name (Required)
Applicant's Mailing Address (Required)
Applicant's E-mail Address (Required)
Daytime Telephone Number (Required)
Fax Number
PART 2: REVOCATION OF AUTHORITY
To revoke the authority of your current representative, check the applicable box in this section. Check only ONE box.
I revoke all prior authorizations and will represent myself in all licensing-related matters with DIFS.
I revoke all prior authorizations and appoint a new representative (as designated in Part 3).
PART 3: REPRESENTATIVE APPOINTMENT
Your representative may be an entity or an individual. If you designate an entity you must also provide an individual as a contact. If no start date is
indicated, the authorization will be effective as of the date this form is signed. If no expiration date is indicated, the authorization will remain effective
until revoked. Revocation may be accomplished only by completing and submitting another copy of this form.
Authorized Representative’s Name and Address (Required)
Contact Name (Required if an entity is named)
Telephone Number (Required)
Fax Number
Authorization Start Date (mm/dd/yyyy)
Authorization Expiration Date (mm/dd/yyyy)
Authorized Representative’s E-mail Address (Required)
PART 4: TYPE OF AUTHORITY
By checking a box or boxes, you authorize your representative to act in that capacity. This section is required.
1. Receive and inspect confidential information (upon request only). To have your representative receive copies of all future written
communications from DIFS, you must also complete Part 5.
2. Communicate via telephone with DIFS regarding this license application.
3. Compile and submit licensing application materials.
4. All of the above.
PART 5: REQUEST COPIES OF WRITTEN COMMUNICATIONS REGARDING A LICENSING APPLICATION
By checking this box, you are directing DIFS to send a copy of all future written communications involving your licensing application to the person
noted in Part 3.
PART 6: APPLICANT AUTHORIZATION
By signing this form, I authorize DIFS to communicate with my representative consistent with the authority granted herein.
Signature (Required)
Printed Name (Required)
Date (Required)
DIFS' USE ONLY
Reviewer's Name
Director’s Designee
Accepted
Rejected
FIS 2312 (4/16) Department of Insurance and Financial Services Page 1 of 2
Issued under authority of Public Act 218 of 1956.
Limited Power of Attorney
INSTRUCTIONS: Use this form to authorize the Michigan Department of Insurance and Financial Services to communicate with a
named individual or entity acting on your behalf. If you choose (see Part 4), such communications will include the disclosure of
confidential information related to your license application.
PART 1: APPLICANT INFORMATION
Applicant's Name (Required)
Applicant's Mailing Address (Required)
Applicant's E-mail Address (Required)
Daytime Telephone Number (Required)
Fax Number
PART 2: REVOCATION OF AUTHORITY
To revoke the authority of your current representative, check the applicable box in this section. Check only ONE box.
I revoke all prior authorizations and will represent myself in all licensing-related matters with DIFS.
I revoke all prior authorizations and appoint a new representative (as designated in Part 3).
PART 3: REPRESENTATIVE APPOINTMENT
Your representative may be an entity or an individual. If you designate an entity you must also provide an individual as a contact. If no start date is
indicated, the authorization will be effective as of the date this form is signed. If no expiration date is indicated, the authorization will remain effective
until revoked. Revocation may be accomplished only by completing and submitting another copy of this form.
Authorized Representative’s Name and Address (Required)
Contact Name (Required if an entity is named)
Telephone Number (Required)
Fax Number
Authorization Start Date (mm/dd/yyyy)
Authorization Expiration Date (mm/dd/yyyy)
Authorized Representative’s E-mail Address (Required)
PART 4: TYPE OF AUTHORITY
By checking a box or boxes, you authorize your representative to act in that capacity. This section is required.
1. Receive and inspect confidential information (upon request only). To have your representative receive copies of all future written
communications from DIFS, you must also complete Part 5.
2. Communicate via telephone with DIFS regarding this license application.
3. Compile and submit licensing application materials.
4. All of the above.
PART 5: REQUEST COPIES OF WRITTEN COMMUNICATIONS REGARDING A LICENSING APPLICATION
By checking this box, you are directing DIFS to send a copy of all future written communications involving your licensing application to the person
noted in Part 3.
PART 6: APPLICANT AUTHORIZATION
By signing this form, I authorize DIFS to communicate with my representative consistent with the authority granted herein.
Signature (Required)
Printed Name (Required)
Date (Required)
DIFS' USE ONLY
Reviewer's Name
Director’s Designee
Accepted
Rejected
FIS 2312 (4/16) Department of Insurance and Financial Services Page 2 of 2
Purpose
Part 4: Type of authority: General or limited.
Use the Limited Power of Attorney (FIS 2312) to
The actions that your representative may take will
authorize the Michigan Department of Insurance and
depend on the boxes that you check in Part 4.
Financial Services (DIFS) to communicate with a
Confidential information (box 1) will only be provided
named individual or entity acting on your behalf. This
upon request; DIFS will not automatically send
form may also be used to revoke your
confidential information to your representative. If you
representative’s authority or to designate a
check box 4 in Part 4, you are granting your
representative to receive confidential information
representative general authority to act on your behalf
regarding a licensing application.
regarding any licensing application materials.
However, granting your representative general
Required information. If a box includes the word
authority does not give the representative the right to
“Required,” you must provide the information. If a box
receive future written communications unless Part 5 is
does not contain the required information, the form is
also completed.
invalid and you will be notified by letter.
Part 5: Requesting all future written
Part 2: Revoking the authority of a representative.
communications related to any licensing
Complete Part 2 only if you want to revoke your
applications.
representative’s authority or all prior authorizations.
If you complete Part 5, you authorize the person
After you revoke your representative’s authority, you
named in Part 3 to receive all future communications
may represent yourself, or you may appoint a new
regarding your licensing application. Part 5 does not
representative.
give a representative authority to act on your behalf.
You must give your representative authority to act on
Part 3: Appointing an entity as your
your behalf by checking one or more boxes in Part 4 if
representative.
you want your representative to do more than just
If you appoint an entity as your representative, then
receive future notices and letters. Only one
any individual within that entity is authorized to act on
representative can be authorized to receive future
your behalf. For example, if you appoint the XYZ
written communications under Part 5. DIFS will only
Company as your representative, any employee of
send future written communications to the person
that firm is authorized to act on your behalf. The
identified on the most recent form. If you appoint an
“Contact Name” is only to ensure that information sent
entity as your representative, future letters and
to the entity is directed to the individual overseeing
notices will be sent to the attention of the first
your representation. The contact name is NOT your
“Contact Name.”
sole authorized representative. To appoint an entity,
write in the Name and Address box (for example):
XYZ Company
Mailing or Faxing Instructions
1234 Street
City, State, ZIP Code
Send the completed, signed, form to:
Appointing an individual as your representative.
General Mailing Address:
If you appoint a specific individual as your
Department of Insurance and Financial Services
representative, then only that individual is authorized
Attention: Insurance Licensing
to act on your behalf. DIFS will only discuss with or
P.O. Box 30220
disclose information to that individual. For example, if
Lansing, Ml 48933
a specific attorney at the XYZ Company is named as
your representative, DIFS will not discuss with or
Fax: 517-284-8836
disclose information to any other attorney or paralegal
at the same firm. To appoint an individual, write in the
Overnight Delivery Address:
Name and Address box (for example):
Department of Insurance and Financial Services
Representative Name
Attention: Insurance Licensing
XYZ Company
530 W. Allegan Street, 7th Floor
1234 Street
Lansing, MI 48933
City, State, ZIP Code
Telephone: 517-284-8800
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