DEPARTMENT
OF FINANCIAL SERVICES
Division of Agent and Agency Services – Bureau of Licensing
200 East Gaines Street, Larson Building Room 419
Tallahassee, FL 32399-0319
AGENT QUALIFICATION AND VERIFICATION OF EXPERIENCE FORM
PERSONAL LINES QUALIFICATIONS STATEMENT
Check one and initial:
Six Months of Experience
I certify that I have six (6) months of responsible duties within the past four (4) years as a substantially full time bona fide
employee in the area of property and casualty insurance AND have sold to individuals and families for noncommercial
purposes.
INITIALS
Six Months Licensed and Appointed
I certify that I have six (6) months of responsible duties within the past four (4) years as a licensed and appointed
4-40 customer representative, 04-42 limited customer representative, or 0-55 service representative lines agent.
INITIALS
EMPLOYER C
ERTIFICATION
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:
Applicant Signature Employer Signature
Print Applicant Name Print Employer Name
Applicant’s Social Security Number Agency Name
Agency Address
City State Zip
