New Agent Membership Form

On October 1, 1997, Florida Insurance Law §626.921 became effective and provided for the creation of Florida Surplus Lines Service Office (FSLSO). FSLSO is a statutorily mandated not-for-profit association of all Florida licensed surplus lines agents. All surplus lines agents shall, as a condition of holding a surplus lines license be deemed a member of the Service Office. This membership form may be used to register as a member of this office.


SURPLUS LINES AGENT INFORMATION
First Name ** MI Last Name ** Suffix
Agent License Number **
Email Address **

AGENT LICENSE ADDRESS
Address 1 **
Address 2
City ** State ** Zip **
Phone Number **
() - Ext.
Fax Number **
() -
ALL OFFICIAL CORRESPONDENCE MUST BE MAILED TO YOUR LICENSE LOCATION. IF YOU WISH US TO MAIL REPORTS AND INVOICES TO OTHER LOCATIONS, PLEASE INDICATE THE ADDRESS BELOW.

AGENT MAILING ADDRESS
Mailing Address is same as License Address
Address 1
Address 2
City State Zip

CONTACT PERSON INFORMATION
First NameLast Name
Email Address
Phone Number
() - Ext.

AGENCY INFORMATION
Agency Name **
Agency License Number **Agency FEIN **
Address 1 **
Address 2
City ** State ** Zip **
Phone Number **
() -
Fax Number **
() -