Fillable Reinsurance Intermediary Application ( Firms) (DFS-H2-1087) (Florida Department of Financial Services)

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Reinsurance Intermediary Application ( Firms) (DFS-H2-1087) (Florida Department of Financial Services)

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DFS-H2-1087
Revised 03/17
Rule 69B-211.002, F.A.C.
Only Choose One:
FIRM RESIDENT REINSURANCE BROKER - TYPE AND CLASS - 0065 (F)
FIRM RESIDENT REINSURANCE MANAGER - TYPE AND CLASS - 0066 (F)
FIRM NONRESIDENT REINSURANCE BROKER - TYPE AND CLASS - 0067 (F)
FIRM NONRESIDENT REINSURANCE MANAGER - TYPE AND CLASS - 0068 (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:
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. Has this firm or any controlling person ever been a defendant in any lawsuit involving claims of fraud, misrepresentation,
conversion, mismanagement of funds or breach of fiduciary duty? Yes No
3. Has this firm or any controlling person ever been charged in any capacity whatsoever with irregularities in money or any
other transaction? Yes No
4. Does any individual or organization claim that this firm or any controlling person is indebted to them for any overdue and
unpaid balance arising out of an insurance or reinsurance transaction? Yes No
5. Has this firm or any controlling person ever been subject of any inquiry or investigation by any Division of the Florida
Department of Financial Services? Yes No
FEES
Application for License – Filing Fee (F) $50.00
License Fee – 0090 (F) $ 5.00
TOTAL FEES ENCLOSED: $
DEPARTMENT OF FINANCIAL SERVICES
Division of Insurance Agent & Agency Services – Bureau of Licensing
200 East Gaines Street, Larson Building
Tallahassee, FL 32399-0319
REINSURANCE INTERMEDIARY APPLICATION
FIRMS
Federal Identification Number
Firm/Business/Agency Name
Business Street Address
Business City
Business County
State
Zip Code
Mailing Address
Mailing City
State
Zip Code
Telephone number
Email Address
DFS-H2-1087
Revised 03/17
Rule 69B-211.002, F.A.C.
6. Has this firm or any controlling person had an occupational, professional or business license, which has been censured,
suspended, revoked, canceled, terminated or been the subject of any type of administrative action in any state including
Florida? Yes No
7. Has this firm or any controlling person ever had an agency contract or reinsurance intermediary contract canceled? If so,
by what company or general agent and what are the reasons for such? Yes No
8. Is this firm or any controlling person now indebted to any court appointed liquidator, any reinsurance or insurance
company, reinsurance intermediary, general agent, or agent? Yes No
9. Has this firm or any controlling person failed to pay any reinsurance or insurance company, or reinsurance intermediary
any premium due to such company, which has come into your possession? Yes No
10. Are there any outstanding final judgments against this firm or against any existing or defunct business, which this firm
controlled? Yes No
11. Are you willing to hereby appoint and name 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 nonresident 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
12. The books and records of the Applicant Reinsurance Intermediary will be maintained at the following location for
examination by the Department:
Contact Person
Address
Telephone Number
13. (a) List all officers, partners and directors and give information requested below:
(List officers first, followed by directors.) Any additional officers and directors should be listed on a separate sheet and
attach it to this application.
(A.) Name
Title
Director?
Yes No
Sex
M F
Will act as Intermediary?
Yes No
Social Security Number
US Citizen?
Yes No
Resident Number and Street
City
State
Zip Code
(B.) Name
Title
Director?
Yes No
Sex
M F
Will act as Intermediary?
Yes No
Social Security Number
US Citizen?
Yes No
Resident Number and Street
City
State
Zip Code
(C.) Name
Title
Director?
Yes No
Sex
M F
Will act as Intermediary?
Yes No
Social Security Number
US Citizen?
Yes No
Resident Number and Street
City
State
Zip Code
(D.) Name
Title
Director?
Yes No
Sex
M F
Will act as Intermediary?
Yes No
Social Security Number
US Citizen?
Yes No
Resident Number and Street
City
State
Zip Code
DFS-H2-1087
Revised 03/17
Rule 69B-211.002, F.A.C.
(b) FAILURE TO ANSWER ALL BLANKS IN THE QUESTION BELOW WILL DELAY THE PROCESSING OF YOUR
APPLICATION.
Have any of the above-listed individuals ever been charged with or convicted of or pleaded guilty or no contest to:
a crime involving moral turpitude? Yes No
a felony? Yes No
a crime punishable by imprisonment of one 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”, state their full name, social security Number, date of birth and place of birth and give dates of each offense:
Name
Social Security Number
Date of Birth
Place of Birth
Dates of Offense
(c) What was the Crime?
(d) Where and when were they charged?
Where?
When?
(e) Did they plead guilty or nolo contendere? Yes No
Were they convicted? Yes No
Was the adjudication withheld? Yes No
(f) Please provide a brief description of the nature of the offense charged. If there has been more that one such felony charge,
provide an explanation as to each charge on an attachment. Certified copies of the Information or Indictment and final
Adjudication for each charge is required.
(g) Have they been arrested or indicted by any state or federal authorities anywhere in the United States, in the last twelve
months? If “Yes”, attach an explanation. Yes No
(h) Are there currently pending against any of the above listed individuals any criminal charges in any state or federal court
anywhere in the United States? If “Yes”, attach explanation. Yes No
(i) Have any of the above listed individuals now or in the last twelve months participated in a Pre-trial Intervention program?
If “Yes”, attach an explanation. Yes No
14. Provide a resume on every director and officer of this firm.
15. Where is this firm domiciled?
State
County
16. How long has this firm operated under this present name? Years, Months
17. Does this firm have offices in more than one location? Yes No
If “Yes” how many locations? Attach the sheet showing the location every office of the firm, anywhere in world.
18. List every name this firm now or previously done business under?
19. How long has this firm operated at the present address? Years, Months
DFS-H2-1087
Revised 03/17
Rule 69B-211.002, F.A.C.
If located at present address less than five years, list all prior addresses in the last five years on a separate sheet.
20. If the firm is a partnership, name all three partners.
21. If this firm is a corporation, name the three largest stockholders.
22. Name every state where this firm is licensed as a Reinsurance Intermediary
23. Provide the name, location and account number of the bank where this firm is or will do its banking.
Name
Location
Account Number
24. Provide the name and address of the firm’s accountants. Any additional accountants should be listed on a separate sheet
and attach it to this application.
Name
Address
Name
Address
Name
Address
Name
Address
25. Provide the name and address of the firm’s attorneys. Any additional attorneys should be listed on a separate sheet and
attach it to this application.
Name
Address
Name
Address
Name
Address
26. Provide the name and address of the firm’s actuary or actuarial consultants if any. Any additional actuary or actuarial
consultants should be listed on a separate sheet and attach it to this application.
Name
Address
Name
Address
Name
Address
Name
Address
DFS-H2-1087
Revised 03/17
Rule 69B-211.002, F.A.C.
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 OFFICER 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
DFS-H2-1087
Revised 03/17
Rule 69B-211.002, F.A.C.
Mail application and fees to:
Florida Department of Financial Services
Bureau of Licensing
Revenue Processing Section
P.O. Box 6100
Tallahassee, Florida 32314-6100
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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