Department of Financial Services

Address of Appointing Entity


{If no license, then use SSN}
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PART II (this is to be completed by all temporary agents, permanent agents, and managing general agents)

Pursuant to Section 648.382 (2)(b), F.S., I do solemnly swear that I owe no premium to any insurer and that I will discharge all outstanding forfeitures and judgments on bonds that may have been previously written.

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PART III (this is to be completed only by permanent agents who are currently or were previously appointed)

Pursuant to Sections 648.442 (8)(a)(b), F.S., I swear that there has been no loss, misappropriation, conversion of theft of any collateral being held by me in trust for any Insurer by which I am or have been appointed. All collateral being held in trust and all records for any Insurer by which I am currently or was previously appointed, are available for immediate audit and inspection by the Department, the Insurer, or the Managing General Agent and will upon demand of the Department of Financial Services be transmitted to the Insurer for whom the collateral is being held in trust.

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PART IV(to be completed by appointing company representative)

Pursuant to Section 648.355(1)(c), F.S., has the applicant listed above plead guilty or nolo contendereto or been found guilty of a felony or crime involving moral turpitude since becoming licensed for the Type and Class of appointment requested herein?
(If yes, attach a separate document describing the circumstances related to this question.)
Under penalties of perjury, I, the undersigned, certify that the answer given above is true and correct and that the person for whom an appointment is requested has been thoroughly investigated as to integrity and character; that his/her reputation is good; and he/she is trustworthy, pursuant to Section 648.382 (2) (a), F.S. I further certify that the appointing entity has or will furnish any information relating to the licensee as requiredby law and that the appointing entity is willing to be bound by the acts of the person being appointed. I certify that Section 648.382, F.S., will be adhered to as it relates to the particular class of appointment being made.
Appointment Fees:

Type/Class - Amount - Enclosed

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