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F Division of Insurance Agent and Agency Services (Florida Department of Financial Services)

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F
LORIDA DEPARTMENT OF FINANCIAL SERVICES
Division of Insurance Agent and Agency Services – Bureau of Licensing
Page 1 of 5
DFS-H2-1088 Rule 69B-211.002, F.A.C.
Revision 03/17
REINSURANCE INTERMEDIARY APPLICATION INDIVIDUAL
Date of Birth
Social Security Number
US Citizen
Yes / No
Last Name
First Name
Middle Initial
Home Address
Home City
State
Zip Code
Home Phone Number
Email Address
Mailing Street Address
Bldg/Suite #
Mailing City
State
Zip Code
Business Street Address
Apt. #
Business City
State
Zip Code
Business Phone Number
TYPE AND CLASS OF LICENSE REQUESTED
Choose Only One
Individual Resident Reinsurance Broker 0061 (F)
Individual Resident Reinsurance Manager 0062 (F)
Individual Nonresident Reinsurance Broker 0063 (F)
Individual Nonresident Reinsurance Manager 0064 (F)
1. Current or previous licenses or registrations: Show last license or registration number if more than one previous
license or registration has been held in a type. If the license number is unknown, indicate “unknown”. If exact
effective dates are unknown, give the best approximation. If no license(s) are held, enter “none”.
License Number
State/County of Issuance
Effective Date: From – To:
Reinsurance Intermediary
Property Casualty
Agent/Broker/Producer
Third Party Administrator
The above question seeks information about whether you are now licensed or registered, or have ever been licensed or registered in any
state or country, including Florida. Please review the question for the specific types of licenses or registrations for which the Florida
Department of Financial Services has requested information. If you answer “no” or “none” or if you leave the questions blank, you are
representing that you do not now hold any of the licenses or registrations specified and that you have never held any of those licenses.
2. List all the states in which you hold any type of insurance license. Please specify what type of license you held in each state.
1
2
3
4
5
3. On a separate page, please summarize your experience in the insurance and reinsurance industry or attach a resume.
4. Provide the name under which you plan to do business as a reinsurance intermediary:
5. How long have you resided at your present address?
No
F
LORIDA DEPARTMENT OF FINANCIAL SERVICES
Division of Insurance Agent and Agency Services – Bureau of Licensing
Page 2 of 5
DFS-H2-1088 Rule 69B-211.002, F.A.C.
Revision 03/17
6. If you have lived less than 5 years at your present address, list all prior resident addresses and the date of each address for the past 5
years on a separate page.
7. Are you self-employed or an employee ? If you are an employee, please name your employer.
FEES
Application for License – Filing Fee (F) $50.00
License Fee - 0090 (F) $ 5.00
TOTAL FEES ENCLOSED: $
Failure to answer all blanks in the questions below will delay the processing of your application.
8. Have you ever been charged with or convicted of or pleaded guilty or no contest to a crime involving moral turpitude, or a felony or a
crime punishable by imprisonment of one (1) year or more under the law of any state, territory or county, whether or not a judgment or
conviction has been entered
Yes No? If “Yes” give dates:
a) What was the crime?
b) Where and when were you charged?
c) Did you plead guilty or nolo contendere? Yes No
d) Were you convicted? Yes No
e) Was adjunction withheld? Yes No
f) Please provide a brief description of the nature of the offense charged:
If there has been more than one felony charge, provide an explanation as to each charge on the attachment. Certified copies of the
information or Indictment and final Adjudication for each charge is required.
g) Have you been arrested or indicted by any state or federal court anywhere in the United States in the last twelve months? Yes
No. If “Yes” please attach explanation.
h) Are there any criminal charges in any state or federal court anywhere in the United States currently pending against you or an entity
you control?
Yes No. If “Yes” please attach explanation.
i) Are you now or have you in the last twelve months participated in a pre-trial intervention program? Yes No
9. Have you ever been a defendant in any lawsuit involving claims of fraud, misrepresentation, conversion, mismanagement of funds, or
breach of fiduciary duty?
Yes No. If “Yes”, provide details on a separate sheet, to include name of parties, state, county or
court, name of court, case number, and brief summary of the issues.
10. Have you ever been charged in any capacity whatsoever with irregularities in money or any other transaction? Yes No
11. Does any individual or organization claim that you as an individual or that any corporation or partnership of which you are or have been
a member are indebted to them for any overdue and unpaid balance arising out of an insurance or reinsurance transactions?
Yes No
F
LORIDA DEPARTMENT OF FINANCIAL SERVICES
Division of Insurance Agent and Agency Services – Bureau of Licensing
Page 3 of 5
DFS-H2-1088 Rule 69B-211.002, F.A.C.
Revision 03/17
12. Have you ever been the subject of any inquiry or investigation by any division of the Florida Department of Financial Services? Yes No
13. Have you or has any occupational, professional or business license held by you been censured, suspended, revoked, canceled, terminated
or been the subject of any type of administrative action in any state including Florida?
Yes No
14. Have you ever had an agency contract or reinsurance intermediary contract canceled? Yes No If yes, by what company or
general agent and what are the reasons for such?
15. Are you now indebted to any court-appointed liquidator, any reinsurance or insurance company, reinsurance intermediary, general agent
or agent?
Yes No
16. Have you failed to pay any reinsurance or insurance company, or reinsurance intermediary any premium due to such company that has
come into your possession?
Yes No
17. Are there any outstanding final judgments against you personally, or against any existing or defunct business which you controlled?
Yes No.
18. Are you willing to hereby name and appoint the Chief Financial Officer of the State of Florida, your attorney to receive service of legal
process issued against you, upon causes of action arising within the State of Florida out of transactions under your Florida non-resident
license and that this appointment shall constitute effective legal service upon you as long as there may be any cause of action against you
arising out of insurance transactions within the State of Florida?
Yes No
19. The books and records of the Applicant Reinsurance Intermediary will be maintained at the following location for examination by the
Department:
Contact Person
Address
City
State
Zip Code
Telephone Number
20. List all employment in the last five (5) years on a separate sheet including the dates.
21. Are there currently any lawsuits pending against you or any entity you control in the courts of any state? Yes No
22. Provide the following information about your attorney:
Name
Address
23. Provide the name and address of your actuary or actuarial consultants, if any.
Name
Address
24. Provide the name, location and account number of the bank where you will do your banking.
Name
Location
Account Number
F
LORIDA DEPARTMENT OF FINANCIAL SERVICES
Division of Insurance Agent and Agency Services – Bureau of Licensing
Page 4 of 5
DFS-H2-1088 Rule 69B-211.002, F.A.C.
Revision 03/17
FINAL STATEMENT
Where required by law, I hereby name and appoint the Chief Financial Officer of the State of Florida my attorney to
receive service of legal process issued against me, upon causes of action arising within the State of Florida out of
transactions under my Florida license; that this appointment shall constitute effective legal service upon me as long as there
may be any cause of action against me arising out of insurance transactions within the State of Florida. (Sections 626.741;
626.742; 626.792; 626.835; 626.836; 626.84201, F.S.)
Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of
his/her official duty shall be guilty of a misdemeanor of the second degree provided under section 837.06, F.S.
Under penalties of perjury, I declare I have read the foregoing application and that the facts stated in it are true to the best
of my knowledge and belief; and that I have not withheld any information that would in any way affect my qualifications. I
understand that misrepresentation of any fact required to be disclosed through this application is a violation of the Florida
Insurance Code and may result in the denial of my application and/or the revocation of my insurance license(s).
I understand that as an applicant who is subject to a national fingerprint-based criminal history record check, I have certain
rights based on Title 28, Code of Federal Regulations (CFR), Section 16.30 – 16.34. The rights include a reasonable time
to respond to the agency for any deficiencies reported in the criminal history report; the ability to challenge the accuracy of
the information in the report by contacting the FBI; and any records held by the agency will be used and retained according
to the FBI’s Criminal Justice Information Services (CJIS) requirements. A copy of the a Noncriminal Justice Applicants
Privacy Rights may be obtained by visiting the agency’s website at https://www.myfloridacfo.com/Division/Agents/ .
I understand that, per section 626.171(5), F.S., all application fees are non-refundable.
SIGNATURE OF APPLICANT DATE SIGNED
Sworn to and subscribed before me this day of , 20
Signature of Notary Public
City
State
Type or Stamp Commissioned
Name of Notary
Personally known or
Produced Identification
Type of Identification Produced
My commission expires (Seal)
Seal
F
LORIDA DEPARTMENT OF FINANCIAL SERVICES
Division of Insurance Agent and Agency Services – Bureau of Licensing
Page 5 of 5
DFS-H2-1088 Rule 69B-211.002, F.A.C.
Revision 03/17
Mail completed application and fees to:
Division of IAAS - Bureau of Licensing
Revenue Processing Section
P.O. Box 6000
Tallahassee, Florida 32314-6000
Privacy Statement
Pursuant to the Privacy Act of 1974, 5 U.S.C. § 552a, the State is responsible for informing you whether disclosure
of your social security number is mandatory or voluntary, by what statutory or other authority your social security
number is solicited, and what uses will be made of your social security number. Under § 119.071(5)(a)2.a., F.S., a
state agency may collect your social security number if the collection is:
(I) specifically authorized by law; or
(II) imperative for the performance of the agency’s duties and responsibilities as prescribed by law.
Disclosure of your social security number on this form is mandatory pursuant to the Welfare Reform Act, 42 U.S.C.
§ 666, and §§ 626.171(2)(a) and (7), 626.231(2)(a), 626.541(1), and 626.9953(3)(a) and (7), F.S.
The purposes for the requested information are to verify the identity of an applicant for licensure, to conduct
criminal and disciplinary history background checks, and to determine if the applicant lacks the fitness or
trustworthiness to engage in the business of insurance. Your social security number is confidential and exempt from
the disclosure requirements of § 119.07(1), F.S., and § 24(a), Article I of the Florida Constitution and will not be
used for any purpose other than the purposes provided herein, or as otherwise authorized under § 119.071(5)(a), F.S.
A copy of this Privacy Statement is provided to you as required by § 119.071(5)(a)3., F.S.
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Completed 20 November 2020

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