DFS-H2-1428
Revision 04/16
AGENT QUALIFICATION AND VERIFICATION OF EXPERIENCE FORM
Experience – One Year
I certify that I have had one (1) year of responsible duties within the past four (4) years as a substantially full time bona
fide employee of surplus lines insurance. I further certify that I understand I must also be licensed and appointed as a
Florida general lines agent in order to qualify to take the surplus lines examination.
Note: You must attach a typed statement with a detailed account of your experience.
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INITIALS
As applicant’s current or prior employer, I certify that the applicant has completed the above experience qualification,
and that compensation did/did not include, in whole or any part, any commissions and was not primarily based in the
production of applications, insurance or premiums, except in cases where the applicant may have been properly
licensed in this or another state and therefore, authorized to receive such compensation. I further certify that this
applicant has not transacted business in violation of the Florida Statutes.
By signature of this form, applicant/employer declares, under penalty of perjury, that the foregoing statements and facts
stated herein are true and correct:
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Applicant Signature Employer Signature
________________________________________ ________________________________________
Print Applicant Name Print Employer Name
________________________________________ ________________________________________
Applicant’s Social Security Number Agency Name
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Agency Address
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City State Zip
*NOTE
You are required by state and federal law to disclose your social security number on this application. Section 666(a)(13)
of Title 42, Unites States Code, requires each state to obtain the social security number of each applicant for a
professional or occupational license on the application for the license. Section 626.171(5), Florida Statutes, implements
this federal law. The purpose of collecting social security numbers is for administration of the child support enforcement
provisions of Title IV-D of the Social Security Act. The Department of Financial Services also uses social security
numbers for identity verification purposes in conjunction with background checks of applicants and for identity
verification purposes in the Department's electronic database for licensees and applicants.
