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Background
Has any member of your company received any disciplinary actions by a State Insurance Department or their regulatory authority?
   
Is the company engaged in, owned by, associated or affiliated with or controlled by any other business interest?
   
Are you a member of:
           
Are you on Florida’s list of eligible E&S carriers?
   
Are you on the federally authorized list of E&S carriers?
   
Please list 3 Surplus Lines Agencies representing you in Florida:
 
1.
2.
3.
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.


  $

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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:
December 14, 2019