DEPARTMENT OF FINANCIAL SERVICES
Division of Agent & Agency Services – Bureau of Licensing
200 East Gaines Street, Larson Building Room 419
Tallahassee, FL 32399-0319
REQUEST FOR EXTENSION OF TIME
The undersigned licensee hereby requests a 90-day extension of time for good cause as defined in Rule 69B-228,
F.A.C., to comply with the education requirements of Section 626.2815, F.S., and Rule 69B-228, F.A.C., for the
following reason(s):
Disabling Accident (explain below, Include doctor letter)
Illness (explain below, Include doctor letter)
Declared Civil Emergency or Disaster (see below)
Other (explain below)
SUPPORTING DOCUMENTATION OF THE ABOVE IS REQUIRED AT THE TIME OF REQUEST.
IN CASES OF DISABLING ACCIDENT OR ILLNESS, MEDICAL DOCUMENTATION FROM TREATING PHYSICIAN
ON OFFICIAL LETTERHEAD IS REQUIRED.
Declared Civil Emergency or Disaster requires documentation from local, state, or national official. Documentation must
include identification of affected counties. If event occurs in the last 15 days of the compliance period, documentation of
registration for courses during that period which could not be attended because of the emergency or disaster must be
included.
NO REQUEST FOR EXTENSION WILL BE CONSIDERED UNLESS ALL DOCUMENTATION IS SUBMITTED AT THE
TIME THE REQUEST IS MADE.
EXPLANATION:
Requests For Extension of Time must be received at least 15 days prior to the close of the compliance period or
current extension period.
Extensions are awarded only in 90 day periods
Requests For Extension of Time must be submitted using this form
Only four (4), 90-day extension periods can be granted for a single compliance period
Any request for more than one 90-day extension period at a time will be reviewed by the Florida Department of
Financial Services prior to approval.
Any request for more than four (4) 90-day periods will be denied.
SIGNATURE
