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FLORIDA DEPARTMENT OF FINANCIAL SERVICES (Florida Department of Financial Services)

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FLORIDA DEPARTMENT OF FINANCIAL SERVICES
Division of Insurance Agent and Agency Services – Bureau of Licensing
Page 1 of 2
DFS-H2-376 Rule 69B-211.002, F.A.C.
Revision 03/17
Application for Life License and Appointment
U.S. Foreign Military Installation
Applicant for license/appointment for a natural person, not a resident of this state, to represent an authorized life insurer
domiciled in this site or an authorized foreign life insurer which maintains a regional home office in this state, provided
such person represents such insurer exclusively on a united states military installation located in a foreign country.
(Section 626.322, F.S.)
Application is hereby made for license/appointment, description shown below (Print or Type All):
1. Name_________________________________________________________________________________________
Last First MI
2. Social Security Number: _________________ Place of Birth: ___________________ Date of Birth: __________
4. Resident Address: ______________________________________________________________________________
Street City State Zip Code
5. Last address in U.S.: ____________________________________________________________________________
Street City State Zip Code
I, the undersigned, for and on behalf of the insurance company, whose name appears upon, do hereby certify that the
individual for whom a license/appointment is requested, has been thoroughly investigated as to integrity and character;
that he has the necessary training to hold himself out as a life insurance representative; and this company is willing to be
bound by the acts of such applicant within the scope of his employment.
Life Insurance Company Name: ____________________________________________, Company Code: __________
Home Office Address (FL): __________________________________________________________________________
Street City State Zip Code
Mailing Address in Foreign Country (For ALL of your correspondence):
______________________________________________________________________________________________
Sworn to and subscribed before me this _____ day of
_______________, 20_____
______________________________________________
Notary Public (Print/Sign)
______________________________________________
City State
(Print, Type, or Stamp Commissioned Name of Notary)
Personally Known OR Produced Identification
Type of Identification Produced: ___________________
My Commission Expires: _________________________
(SEAL)
_____________________________________________
Company Official (Print/Sign)
_____________________________________________
Title Date
Mail Completed Form to:
Revenue Processing Section
P.O. Box 6000
Tallahassee, FL 32314-6000
FEES ARE NON-REFUNDABLE
Application for License-Filling Fee $ 50 0093 (F)
I.D. License Fee $ 5 0090 (F)
Appointment Fee $ 20 0093 (L)
TOTAL FEES ENCLOSED: $_____________
FLORIDA DEPARTMENT OF FINANCIAL SERVICES
Division of Insurance Agent and Agency Services – Bureau of Licensing
Page 2 of 2
DFS-H2-376 Rule 69B-211.002, F.A.C.
Revision 03/17
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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FLORIDA DEPARTMENT OF FINANCIAL SERVICES (Florida Department of Financial Services)

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Completed 20 November 2020

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