DFS-H2-1105
Revised 06/14
DEPARTMENT OF FINANCIAL SERVICES
Division of Agent & Agency Services – Bureau of Licensing
200 East Gaines Street Larson Building, Room 419
Tallahassee, FL 32399-0319
AFFIDAVIT OF INSURANCE ACTIVITY WHILE NOT PROPERLY APPOINTED
DO NOT SEND AN APPOINTMENT FORM WITH THIS AFFIDAVIT
This affidavit is to be used when an appointing entity has an agent, adjuster or other insurance representative who
has been actively engaged in transacting insurance or adjusting claims without an appointment. The Department will
be in contact with the appointing entity upon completion of its review of the information provided. Please mail this form
to the address listed above or email to AgentLicensing@MyFloridaCFO.com.
Note: A licensee is responsible for maintaining their required Continuing Education (CE) hours for all CE cycles
associated with their license and should ensure their CE hours are current for all their CE cycles. If a license has expired
due to lack of an appointment, the licensee is required to submit new fingerprints per subsection 626.171(4), F.S., before
this affidavit can be processed. Fingerprint information can be found at:
www.MyFloridaCfo.com/Division/Agents/Licensure/Agents-Adjusters/fingerprinting.htm
Enter the pertinent information below:
1. The individual, __________________________________, whose license ID# is ________________, has been
actively engaged in the transacting of insurance on behalf of:
Name of Appointing Entity
Appointing Entity Number
Email Address
Mailing Address
City
State
Zip Code
2. This individual has been transacting insurance business without an appointment since ___________________
for the following type and class (ex: Life & Variable Annuity, 2-14; or, General Lines, 2-20; etc.,):
3. State the reason for failure to appoint licensee as required by Section 626.112, Florida Statutes:
Appointing Entity Official Information:
Name
Title
Telephone Number
Email Address
Under penalty of perjury, pursuant to section 626.112, F.S., I declare that the above statements and entered
information are true to the best of my knowledge.
Print Name of the Appointing Entity Official Signature of the Appointing Entity Official
9413 - NON-RESIDENT TITLE AGENT
