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Please indicate your business structure:
Please list 3 Surplus Lines Agencies representing you in Florida:
 
1.
2.
3.
Background
During the last 5 years, has the firm acquired/merged with another firm?
    
Has the firm changed names?
    
Is the firm engaged in, owned by, associated or affiliated with, or controlled by any other business interest?
    
Has any member of your firm received any disciplinary actions by a State Insurance Department or their regulatory authority?
    
Professional Associations to which you belong:
Check all that apply.
              
Principals and Personnel
Breakdown of the firm's staff: Current Year Previous Year
Number of Principals / Partners / Owners
Number of Officers / Managers
Number of Brokers
Number of Other Employees
Total Number of Staff
Owners (List in order of % of ownership)
Name Title / Position Year Started in Insurance Year Started with the Firm % of Ownership Email FL Insurance License Type FL Insurance License Number National Producer Number
Operations
Do you write business outside of the State of Florida?      
Does your firm operate as a Wholesaler?
         
Company Representation
List Major Companies Represented:
Name Years Represented Binding Authority? Admitted?
Describe scope of Binding Authority
(i.e., Limit of Authority, Line of Insurance, etc.)
Please list any companies discontinued in the last 5 years:
FSLA Annual Membership
Membership Level:
SurPac Suggested Contribution
Political action committees promote the welfare of the Florida Surplus Lines agent by helping elect those candidates who support the wholesale system and related issues. As a contributing member you help achieve that goal. Any individual or company may contribute any amount. This is a non-deductible voluntary contribution.


  $

Payment Information
* Name On Card:
* Billing Zip:
* Credit Card Number:
* Expiration Date:
* CVV2 Code:
Total Due:
$0.00

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Notice: Florida Surplus Lines Association dues are not deductible as a charitable contribution for federal tax purposes, but may be deductible as a business expense. The current tax code eliminates the portion of your dues attributable to lobbying expenses. It has been determined that 46% of your dues are used for these purposes, therefore only 54% of your dues are deductible as a business expense.

BY SUBMITTING THIS FORM, I HEREBY DECLARE THAT THE ANSWERS GIVEN WITH RESPECT TO THE FOREGOING QUESTIONS ARE TRUE, COMPLETE, AND ACCURATE WITH NO MISREPRESENTATION, OMISSIONS, OR ANY OTHER CONCEALMENT OF FACT.
Name of Applicant:
Title of Applicant:
Date of Application:
March 24, 2019