Form Dfs H2 1428 PDF Details

Navigating the complex landscape of insurance licensing in Florida requires attention to detail and a thorough understanding of the necessary prerequisites. The DFS H2 1428 form serves as a critical step in this process, offered by the Department of Financial Services' Division of Agent & Agency Services – Bureau of Licensing. Situated at the heart of Tallahassee, this document helps to structure the pathway for agents to validate their qualifications and experiences across a variety of insurance domains, including General Lines, Personal Lines, Title Agent, Customer Representative, and more. With the requirement to check the appropriate license application box, complete, and initial specific sections, the form meticulously guides applicants through their journey. It demands evidence of experience in all necessary areas, from handling insurance duties full-time to completing the required pre-licensing courses pending on the license type. Additionally, the form captures vital information about the applicant's employment history, including certification from employers about the completion of required experience and adherence to Florida's statutory regulations. This detailed procedure underscores the importance of accuracy, completeness, and truthfulness, all underlined by the legal implications of signing the form under penalty of perjury. By capturing an array of qualifications and experiences, the DFS H2 1428 form stands as a gateway for aspiring insurance professionals, shaping the integrity and reliability of the industry’s workforce in Florida.

QuestionAnswer
Form NameForm Dfs H2 1428
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesAbstracting, Surety, inquires, licensees

Form Preview Example

DEPARTMENT OF FINANCIAL SERVICES

Division of Agent & Agency Services – Bureau of Licensing

200 East Gaines Street, Larson Building Room 419

Tallahassee, FL 32399-0319

AGENTS QUALIFICATION AND VERIFICATION OF EXPERIENCE

Check the appropriate box of the license you are applying for, then complete and initial the appropriate section:

2-20 General Lines

20-44 Personal Lines

4-10 Title Agent

4-40 Customer Representative

4-42 Limited Customer Representative

1-20 Resident Surplus Lines

91-20 Non Resident Surplus Lines

GENERAL LINES QUALIFICATIONS STATEMENT

I certify that I have completed at least 1 year in responsible insurance duties, as a substantially full time bona fide employee in all lines of Property and Casualty insurance.

NOTE: Please indicate the specific nature of experience you have in the lines of insurance required for this license by checking the appropriate box(es)

EXPERIENCE IS REQUIRED IN ALL OF THESE AREAS IN ORDER TO QUALIFY BY THIS METHOD.

Adjusters experience will not qualify for the 2-20 General Lines Examination

Customer Representative

I certify that I have had one (1) year of responsible duties as a licensed and appointed customer representative in personal or commercial lines of property and casualty insurance.

I further certify that I understand I must also complete a department approved 40 hour General Lines Pre-Licensing Course in order to qualify to take the General Lines examination.

Service Representative

Marine

Casualty

Health

Property

Surety

 

 

________

 

INITIALS

________

INITIALS

I certify that I have had one (1) year of responsible duties as a licensed and appointed service representative in personal or commercial lines of property and casualty insurance. I further certify that I understand I must also complete a department approved 80 hour General Lines Pre-Licensing Course in order to qualify to take the General Lines Examination.

________

INITIALS

PERSONAL LINES QUALIFICATIONS STATEMENT

Personal Lines Agent You must select one of the following:

I certify that I have had Three (3) months of responsible insurance experience and have completed an approved correspondence course.

________

INITIALS

I certify that I have completed six (6) months of responsible insurance duties as a

licensed AND appointed Customer Representative or Limited Customer Representative in

Property and Casualty Insurance and have completed a 20 hour pre-licensing course.

________

INITIALS

I certify that I have completed six (6) months of responsible insurance duties as a licensed AND appointed Service Representative in property and casualty insurance and have completed a 40 hour pre-licensing classroom course.

________

INITIALS

I certify that I have completed three (3) years of responsible insurance duties as a licensed

AND appointed Customer Representative

________

INITIALS

DFS-H2-1428

Revised 11/05

SURPLUS LINES QUALIFICATION STATEMENT

Surplus Lines

I certify that I have had one (1) year experience working for a Surplus Lines Agent.

________

INITIALS

CUSTOMER REPRESENTATIVE QUALIFICATION STATEMENT

I certify that I have completed the following for a period no less than six months, within the last two years: Devoted full-time to clerical work, including incidental taking of insurance application; or Quoted or received premiums on incoming inquires; or

Handled daily reports and accounts with insurance companies; and

Gained a general knowledge of office management in the operation of general lines or Surplus lines agency, whichever is applicable.

________

INITIALS

TITLE AGENT QUALIFICATION STATEMENT

I certify that I have devoted full-time for a period of no less than one year, within the past four years, to title insurance with title experience in the following related duties (Check appropriate boxes):

Abstracting and title searches

Title Examination

Preparation of title insurance policies

Closing documents

Handling escrow and trust funds

Disbursement of trust funds

Preparation of documents

Recording documents

 

Gaining general knowledge of title insurance work and office management in the operation of a title insurance office

________

INITIALS

EMPLOYER CERTIFICATION

As applicant’s employer, I certify that the applicant has completed the above experience qualification, and that compensation did/did not include, in whole or any part, any commissions and was not primarily based in the production of applications, insurance or premiums, except in cases where the applicant may have been properly licensed in this or another state and therefore, authorized to receive such compensation. I further certify that this applicant has not transacted business in violation of the Florida Statutes.

________

INITIALS

SIGNATURE

By signature of this form, applicant/employer declares, under penalty of perjury, that the foregoing statements and facts stated herein are true and correct:

________________________________________

_________________________________

Signature of Applicant

Type Name of Applicant

 

 

 

_________________________________

 

Applicant’s Social Security Number

 

________________________________________

_________________________________

Signature of Employer/Agency

Type Name of Employer/Agency

 

 

_________________________________

 

Employer/Agency Address

 

 

 

_________________________________

 

City

State

Zip

*NOTE

You are required by state and federal law to disclose your social security number on this application. Section 666(a)(13) of Title 42, Unites States Code, requires each state to obtain the social security number of each applicant for a professional or occupational license on the application for the license. Section 626.171(5), Florida Statutes, implements this federal law. The purpose of collecting social security numbers is for administration of the child support enforcement provisions of Title IV-D of the Social Security Act. The Department of Financial Services also uses social security numbers for identity verification purposes in conjunction with background checks of applicants and for identity verification purposes in the Department's electronic database for licensees and applicants.

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This form requires specific information to be typed in, therefore be sure you take your time to provide exactly what is asked:

1. It is critical to complete the Larson accurately, therefore be mindful when working with the segments containing these specific blank fields:

Part no. 1 for filling in dfs h2 1124 form

2. Once this part is completed, go on to type in the applicable information in these: Personal Lines Agent You must, I certify that I have had Three, completed an approved, I certify that I have completed, licensed AND appointed Customer, I certify that I have completed, appointed Service Representative, I certify that I have completed, AND appointed Customer, DFSH Revised, INITIALS, INITIALS, INITIALS, and INITIALS.

completed an approved, I certify that I have had Three, and INITIALS in dfs h2 1124 form

3. This third part is going to be straightforward - fill out every one of the form fields in Surplus Lines, I certify that I have had one, CUSTOMER REPRESENTATIVE, I certify that I have completed, Surplus lines agency whichever is, INITIALS, INITIALS, TITLE AGENT QUALIFICATION STATEMENT, I certify that I have devoted, Abstracting and title searches, Title Examination Handling escrow, Preparation of title insurance, EMPLOYER CERTIFICATION, INITIALS, and As applicants employer I certify to conclude the current step.

Surplus lines agency whichever is, Preparation of title insurance, and As applicants employer I certify in dfs h2 1124 form

4. Your next section requires your attention in the subsequent areas: By signature of this form, Type Name of Applicant, Signature of EmployerAgency, Applicants Social Security Number, Type Name of EmployerAgency, EmployerAgency Address, City, State, and Zip. Make sure that you provide all requested details to go further.

Step number 4 of submitting dfs h2 1124 form

People frequently get some things incorrect when filling out EmployerAgency Address in this section. You should definitely reread everything you enter here.

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