Fillable CANCELLATION NOTICE for INSURANCE AGENCY LICENSURE (Florida Department of Financial Services)

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CANCELLATION NOTICE for INSURANCE AGENCY LICENSURE (Florida Department of Financial Services)

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DEPARTMENT OF FINANCIAL SERVICES
Division of Agent & Agency Services – Bureau of Licensing
200 East Gaines Street Larson Building, Room 419
Tallahassee, FL 32399-0319
Please mail this form to:
Department of Financial Services
Division of Agent & Agency Services – Bureau of Licensing
200 East Gaines Street, Larson Building, Room 419
Tallahassee, Florida 32399-0319
DFS-H2-1997
Rev. 11/2012
Rule 69B-211.002
CANCELLATION NOTICE for INSURANCE AGENCY LICENSURE
Agency Name:
Agency License #:
Street:
City:
State:
I certify that the above agency is no longer transacting insurance for Florida. I request to
cancel the agency license effective upon the Department’s receipt of this notice.
*The cancellation notice must be signed and dated by the owner, president, secretary or
other officer listed on the original application for licensure.
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CANCELLATION NOTICE for INSURANCE AGENCY LICENSURE (Florida Department of Financial Services)

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Completed 20 November 2020

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