Credit Reporting Form
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DEPARTMENT OF FINANCIAL SERVICES
Division of Agent & Agency Services – Bureau of Licensing
200 East Gaines Street Larsen Building Room 419
Tallahassee, Fl 32399-0319
Note: Section 626.521, F.S. requires
This form is to be completed by a
That the insurer, its manager, general
company official, manager, general
Agent, or representatives shall secure
agent, or representative ONLY;
And keep on file a full detailed credit
NEVER by the applicant.
And character report on each
Individual qualifying for the first time.
SUMMARY
CHARACTER AND CREDIT REPORT
THIS IS A PRIVILEGED COMMUNICATION
This report must be a summary of the detailed credit and character report that you have obtained from an established
and reputable independent credit reporting service as required by law. (See note above).
1.
First Name
Middle Initial
Last Name
Social Security
Race
Sex (M/F)
M
F
*Has subject been known by any name other than his legal name; or used any Social Security number other
that his legal one; or is there any other discrepancies of birth date on any available legal documents?
If YES, please furnish complete details on a separate sheet of paper and attach same to this report.
2.
Date of Birth
Place of Birth
Home Street Address
City
State
Zip
Business Address
City
State
Zip
3.
Give residence street addresses for the past FIVE years (include dates):
4.
Date (From/To)
Name of Employer
Complete Business
Occupation/
Reason for
Address
Position Held
Leaving
5.
Has subject ever been licensed in this or any other state?
If so, give details including date license(s) was canceled and state(s) where licensed:
6.
Has subject ever had an application for a license declined, denied, suspended, revoked, placed on
probation or administrative fined levied; or voluntarily surrendered his insurance license?
If YES, please provide complete details.
DFS-H2-38
Revised 9/07
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