DFS-H2-6364
Revised 09/17
INSTRUCTIONS – Do NOT send this page
SPECIAL NOTE TO THE DESIGNATED PRIMARY ADJUSTER
When an updated form is filed designating another primary adjuster, the previous designee will no longer be considered the
current primary adjuster for that designated location. If you should leave the adjusting firm you will still be considered the
primary adjuster until the adjusting firm files a new form. If you will no longer be working at the adjusting firm location as the
designated primary adjuster, you are advised to submit this form with item numbers two and three completed and the
appropriate delete box checked with your signature in the space provided. Failure to remove yourself as the primary
adjuster may result in you continuing to be held responsible for the activities of the adjusting firm until a new designation is
made.
INSTRUCTIONS FOR COMPLETING PRIMARY AGENT/PRIMARY ADJUSTER FORM
To be completed by each person operating an adjusting firm and for each location of multiple adjusting firm (See definitions
of adjusting firm shown below).
Each business location established by an adjuster, an adjusting firm, a corporation, or an association must designate with
the department a primary adjuster who is licensed and appointed to adjust the insurance claims adjusted by the business
location. The primary adjuster may be the same person listed in section 1. If the adjusting firm listed in section 2 is not a
corporation, then use the social security number of the individual owner in place of the Federal ID (See definitions of primary
adjuster shown below).
One form is required for each designation or deletion. The same form CANNOT be used for both. The signature of the
primary adjuster is required for each adjusting firm location in order for the designation or deletion to be valid.
DEFINITIONS
Section 626.8695(3), Florida Statutes: Primary Adjuster is the licensed adjuster who is responsible for the supervision of all
individuals within an adjusting firm location who act in the capacity of an adjuster. Note: An adjuster may be designated as
a primary adjuster for more than only one adjusting firm location provided no person engages in activity requiring licensure
as an adjuster at any location when an adjuster is not physically present.
Section 626.8695(4), Florida Statutes: An Adjusting Firm is a location where an independent or public adjuster is engaged
in the business of insurance.
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., F.S., a state agency
may collect your social security number if the collection is specifically authorized by law or if it is 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.
