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DEPARTMENT OF FINANCIAL SERVICES Division of Insurance Agent (Florida Department of Financial Services)

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DFS-H2-501
Rev. 06/2014
Rule 69B-211.002, F.A.C.
1
DEPARTMENT OF FINANCIAL SERVICES
Division of Insurance Agent & Agency Services – Bureau of Licensing
200 East Gaines Street, Larson Building, Room 419
Tallahassee, FL 32399-0319
APPOINTMENT EXCEPTION FORM
FILING INSTRUCTIONS
The Florida Department of Financial Services online appointment process, eAppoint, must be used for effectuating new appointments
and may be accessed on the Department’s website at http://www.MyFloridaCFO.com/Division/Agents. This form is only to be used
at the instruction of the Department. If you have not already obtained approval to submit this form, please call us at (850) 413-3137.
All forms submitted without prior approval will be returned. Once approval has been granted you will need to forward this
completed form along with any required fees to the Department. This form can be duplicated as long as it is a clear and legible copy.
All forms, which are not clear and legible, will be returned.
Name & Address of Appointing Entity: This is the insurance company or licensee who is granting the appointment.
Company Code: This is the insurer’s company code issued by the Office of Insurance Regulation.
License Number: The license number of the licensee to be appointed. Temporary licensees not assigned a license number may use their social
security number.
Name: Name of the person to be appointed, which is to be listed as last name, then the first name, then the middle initial.
Business County Code: The code number of the county where the licensee’s office is located.
Type & Class: The license type that is being appointed.
Appt. Fee: The amount of the fee to accompany this form as shown at the bottom of the form.
Appointment Date: The date this appointment is to become effective.
Appointment Fees: Please check the appropriate box and list the amount of the check accompanying the form.
Appointing Official: This is the signature, printed name and title of the person appointing the licensee. This section should list the date the form is
being signed & business phone number to be used for questions.
Please note: Payment must accompany this form.
Send completed form to:
Florida Department of Financial Services
Bureau of Licensing
Revenue Processing Section
Post Office Box 6100
Tallahassee, Florida 32314-6100
DFS-H2-501
Rev. 06/2014
Rule 69B-211.002, F.A.C.
2
Name and Address of Appointing Entity State of Florida
Department of Financial Services
Bureau of Licensing
Revenue Processing Section Company Code
Post Office Box 6100
Tallahassee, FL 32314-6100
Part I (State Appointment)
Appointment Form
Print or Type
SECTION: 1
2
3
5
6
License Number
Last Name, First Name and Middle Initial
Business
County
Code*
Appt.
Fee
Appointment Date
*The County Codes are listed below and noted as the number preceding the county name, for example, the Country Code for Columbia County is 29.
Licensee must have a state appointment ($60.00) for your company. In addition, indicate the counties in which you wish the agent to be appointed by marking the
appropriate boxes ($6.00 per county). If you wish the agent to be appointed in all Florida counties, mark the appropriate box ($402). *NOTE: Pursuant to Section
624.505 (2), Florida Statutes, in addition to a state appointment, if a nonresident agent personally solicits insurance in Florida, a county appointment is
required for each county in which he/she personally solicits. The county fee is $6 per county.
01
Dade
C $6
15
Manatee
C $6
29
Columbia
C $6
43
Okaloosa
C $6
57
Okeechobee
C $6
02
Duval
C $6
16
Sarasota
C $6
30
Hardee
C $6
44
Sumter
C $6
58
Calhoun
C $6
03
Hillsborough
C $6
17
Seminole
C $6
31
Suwannee
C $6
45
Bradford
C $6
59
Franklin
C $6
04
Pinellas
C $6
18
Lee
C $6
32
Indian River
C $6
46
Jefferson
C $6
60
Glades
C $6
05
Polk
C $6
19
Brevard
C $6
33
Santa Rosa
C $6
47
Citrus
C $6
61
Flagler
C $6
06
Palm Beach
C $6
20
St. Johns
C $6
34
Desoto
C $6
48
Clay
C $6
62
Lafayette
C $6
07
Orange
C $6
21
Gadsden
C $6
35
Madison
C $6
49
Hendry
C $6
63
Union
C $6
08
Volusia
C $6
22
Putnam
C $6
36
Walton
C $6
50
Washington
C $6
64
Collier
C $6
09
Escambia
C $6
23
Bay
C $6
37
Taylor
C $6
51
Holmes
C $6
65
Wakulla
C $6
10
Broward
C $6
24
St. Lucie
C $6
38
Monroe
C $6
52
Baker
C $6
66
Gulf
C $6
11
Alachua
C $6
25
Jackson
C $6
39
Levy
C $6
53
Charlotte
C $6
67
Liberty
C $6
12
Lake
C $6
26
Osceola
C $6
40
Hernando
C $6
54
Dixie
C $6
13
Leon
C $6
27
Highlands
C $6
41
Nassau
C $6
55
Gilchrist
C $6
14
Marion
C $6
28
Pasco
C $6
42
Martin
C $6
56
Hamilton
C $6
111
All Counties
$402
PART III (MUST BE COMPLETED)
I, the undersigned, certify that the person, for whom this appointment is requested, has been thoroughly investigated as to integrity and character: that his/her reputation
and moral character is good; and he/she is trustworthy. I have verified that the person listed in this submittal has not pled guilty or nolo contendere (no contest) to or
been found guilty of a felony or a crime punishable by imprisonment of 1 year or more since becoming licensed for the type and class of appointment(s) requested
herein.
I further certify that the appointing entity has or will furnish any information relating to the licensee as required by law and that the appointing entity is willing to be
bound by the acts of the person being appointed. I certify that sections 626.451, 626.7453, 626.8419, 626.8421, and/or 635.051, F.S., will be adhered to as they relate to
the particular class of appointment being made.
If appointing a nonresident agent/adjuster, I certify that the nonresident agent/adjuster listed is currently qualified and licensed in good standing through the insurance
department of his/her state of residence for the class of appointment submitted.
If appointing a title agency, I certify that the title agency listed has obtained errors and omissions insurance in an amount acceptable to us but not less than $250,000 per
claim and an aggregate limit with a deductible no greater than $10,000, has obtained a fidelity bond in an amount acceptable to us, but not less than $50,000, and has
obtained a surety bond in an amount not less than $35,000 made payable to the title insurer or title insurers appointing the agency.
If appointing a customer representative or limited customer representative, a licensed and appointed general lines agent must sign as the Appointing Official when
appointing a customer representative or limited customer representative. The general lines agent must complete and submit form DFS-H2-1124 - “DESIGNATION OF
SUPERVISING AGENT” to the Department along with this form. Please retain a copy in your agency records.
Signature of the Appointing Official
Print or Type Name of Appointing Entity Official
Appointing Official Title Date
Business Telephone Number License ID# (if applicable)
PART II
(Must
be
completed
if
applying
for
NONRESIDENT
ONLY
–
*County
Appointments.)
FEES ENCLOSED
Appointment Fees
CODE
Amt
#
Total
Initial Appt Fee
$60
=
$
Appt Late Fee
7100J
$250
=
$
Renewal Appt Fee
$60
X
=
$
Renewal Late Fee
7101J
$25
X
=
$
County Appt Fee
$6
X
=
$
Total Amount
$
2
State Appointment Fee
CLASSES OF INSURANCE SORTED BY DESCRIPTION CLASSES OF INSURANCE SORTED BY CLASS
DESCRIPTION CLASS FEES
DESCRIPTION CLASS
FEES
All Lines Adjuster
6-20
$60
Service Representative
0-55
$60
All Lines Public Adjuster
3-20
$60
Managing General Agent
0-60
$60
All Lines Public Adjuster Apprentice
31-20
$60
Individual Resident Reinsurance Broker
0-61
$60
Baggage & Motor Vehicle Excess Liability
2-23
$60
Individual Resident Reinsurance Manager
0-62
$60
Credit
2-29
$60
Individual Nonresident Reinsurance Broker
0-63
$60
Crop Hail & Multi-peril Crop
4-30
$60
Individual Nonresident Reinsurance Manager
0-64
$60
Customer Representative
4-40
$60
Firm Resident Reinsurance Broker
0-65
$60
Firm Nonresident Reinsurance Broker
0-67
$60
Firm Resident Reinsurance Manager
0-66
$60
Firm Nonresident Reinsurance Manager
0-68
$60
Firm Nonresident Reinsurance Broker
0-67
$60
Firm Resident Reinsurance Broker
0-65
$60
Firm Nonresident Reinsurance Manager
0-68
$60
Firm Resident Reinsurance Manager
0-66
$60
Military Registration (Life Insurance)
0-93
$20
General Lines (Prop. & Cas. Ins.)
2-20
$60
Surplus Lines
1-20
$150
Health
2-40
$60
Life including Variable Annuity
2-14
$60
Home Warranty Representative
2-51
$60
Life, Health and Variable Annuity
2-15
$60
In-transit & Storage Personal Property
2-31
$60
Life
2-16
$60
Individual Nonresident Reinsurance Broker
0-63
$60
Life & Health
2-18
$60
Individual Nonresident Reinsurance Manager
0-64
$60
General Lines (Prop. & Cas. Ins.)
2-20
$60
Individual Resident Reinsurance Broker
0-61
$60
Motor. Veh. Phy. Dam. & Mech. Brkdwn.
2-21
$60
Individual Resident Reinsurance Manager
0-62
$60
Baggage & Motor Vehicle Excess Liability
2-23
$60
Industrial Fire or Burglary
2-33
$60
Credit
2-29
$60
Legal Expense
2-56
$60
In-transit & Storage Personal Property
2-31
$60
Life
2-16
$60
Portable Electronics
2-32
$60
Life & Health
2-18
$60
Industrial Fire or Burglary
2-33
$60
Life, Health and Variable Annuity
2-15
$60
Health
2-40
$60
Life & Variable Annuity
2-14
$60
Travel
2-41
$60
Managing General Agent
0-60
$60
Home Warranty Representative
2-51
$60
Military Registration (Life Insurance)
0-93
$60
Service Warranty Representative
2-52
$60
Motor Veh. Phy. Dam. & Mech. Brkdwn.
2-21
$60
Motor Vehicle Service Agreement Salesperson
2-53
$60
Motor Vehicle Service Agreement Salesperson
2-53
$60
Legal Expense
2-56
$60
Nonresident All Lines Adjuster
7-20
$60
Viatical Settlement Broker
2-66
$60
Nonresident All Lines Public Adjuster
73-20
$60
All Lines Public Adjuster
3-20
$60
Nonresident Credit
9-29
$60
Title Agent
4-10
$60
Nonresident Customer Representative
9-40
$60
Title Agency
4-12
$60
Nonresident Gen. Lines (Prop. & Cas. Ins.)
9-20
$60
Nonresident Title Agency
4-13
$60
Nonresident Health
8-40
$60
Crop Hail & Multi-peril Crop
4-30
$60
Nonresident Industrial Fire & Burglary
9-33
$60
Customer Representative
4-40
$60
Nonresident Legal Expense
9-56
$60
All Lines Adjuster
6-20
$60
Nonresident Life
8-16
$60
Nonresident All Lines Adjuster
7-20
$60
Nonresident Life & Health
8-18
$60
Nonresident Life & Variable Annuity
8-14
$60
Nonresident Life, Health & Variable Annuity
8-15
$60
Nonresident Life, Health & Variable Annuity
8-15
$60
Nonresident Life & Variable Annuity
8-14
$60
Nonresident Life
8-16
$60
Nonresident Mtr. Veh. Phy. Dam. & Mech. Brkdwn
9-21
$60
Nonresident Life & Health
8-18
$60
Nonresident Personal Lines
90-44
$60
Nonresident Health
8-40
$60
Nonresident Portable Electronics
9-32
$60
Nonresident Viatical Settlement Broker
8-66
$60
Nonresident Portable Electronics Lead
90-32
$60
Nonresident Gen. Lines (Prop. & Cas. Ins.)
9-20
$60
Nonresident Surplus Lines
91-20
$150
Nonresident Mtr. Veh. Phy. Dam. & Mech. Brkdwn
9-21
$60
Nonresident Title Agency
4-13
$60
Nonresident Credit
9-29
$60
Nonresident Title Agent
94-13
$60
Nonresident Portable Electronics
9-32
$60
Nonresident Viatical Settlement Broker
8-66
$60
Nonresident Industrial Fire & Burglary
9-33
$60
Personal Lines
20-44
$60
Nonresident Customer Representative
9-40
$60
Portable Electronics
2-32
$60
Nonresident Legal Expense
9-56
$60
Portable Electronics Lead
20-32
$60
Portable Electronics Lead
20-32
$60
Service Representative
0-55
$60
Personal Lines
20-44
$60
Service Warranty Representative
2-52
$60
All Lines Public Adjuster Apprentice
31-20
$60
Surplus Lines
1-20
$150
Nonresident All Lines Public Adjuster
73-20
$60
Title Agency
4-12
$60
Nonresident Portable Electronics Lead
90-32
$60
Title Agent
4-10
$60
Nonresident Personal Lines
90-44
$60
Travel
2-41
$60
Nonresident Surplus Lines
91-20
$150
Viatical Settlement Broker
2-66
$60
Nonresident Title Agent
94-13
$60
DFS-H2-501
Rev. 06/2014
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DEPARTMENT OF FINANCIAL SERVICES Division of Insurance Agent (Florida Department of Financial Services)

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