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During the preceding calendar year, pursuant to Section (Florida Department of Financial Services)

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DFS-H2-569
Revised 09/95 Rule 69B-211.002, F.A.C.
DEPARTMENT OF FINANCIAL SERVICES
Division of Insurance Agent and Agency Services – Bureau of Licensing
200 East Gaines Street, Larson Building Room 419
Tallahassee, FL 32399-0319
REGISTRATION OF FRATERNAL BENEFIT SOCIETY REPRESENTATIVES
During the preceding calendar year, pursuant to Section 632.634 (3), F.S., the following solicited
and procured life insurance benefit contracts in a total amount of insurance of less than $50,000 or
have written any kind or kinds of insurance benefit contracts our society writes on not more than 25
individuals.
NAME OF INDIVIDUAL
RESIDENCE ADDRESS
Name of Fraternal Benefit Society
Address
Authorized Signature and Title Date
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During the preceding calendar year, pursuant to Section (Florida Department of Financial Services)

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Completed 20 November 2020

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