VENDOR APPLICATION - DMS
STATE OF FLORIDA STATE PURCHASING
DEPARTMENT OF Bureau of Procurement
Bldg. 4050, Suite 335
4050 Esplanade Way
MANAGEMENT SERVICES Tallahassee, Florida 32399-0950
VENDOR APPLICATION
INSURANCE SUPPLEMENT
FIRM NAME:
OFFICE ADDRESS:
TELEPHONE:
CITY: STATE: ZIP CODE:
1. INDICATE YOUR CLASS OF BUSINESS.
← INSURANCE COMPANY
← INSURANCE AGENCY
← INSURANCE CONSULTANT
2. LIST THE NAMES OF INSURANCE COMPANIES YOUR FIRM REPRESENTS.
A.
B.
C.
D.
E.
3. LIST ANY SPECIALY COVERAGE THAT YOUR FIRM MARKETS.
A.
B.
C.
PUR 7020 (REV. 03/99)
4. DOES YOUR FIRM HAVE THE FACTILITIES TO SERVICE INSURANCE CONTRACTS ON A STATEWIDE BASIS YES ( NO (
5. LIST THE NAMES AND LICENSE NUMBERS OF ALL THE LICENSED RESIDENT AGENTS EMPLOYEED BY YOUR FIRM.
NAME LICENSE NO. LICENSE TYPE
(Social Security No.)
A.
B.
C.
D.
E.
INSURANCE
← 477-090 ACCIDENT & HEALTH
← 477-270 AIRCRAFT
← 477-360 AUTOMOBILE
← 477-450 BOILER & MACHINERY
← 477-500 LIFE
← 477-540 BOND
← 477-590 CLAIM AND ENGINEERING SERVICE
← 477-630 CRIME
← 477-810 LIABILITY
← 477-860 INLAND MARINE
← 477-910 OCEAN MARINE
← 477-960 PROPERTY
← 477-970 TITLE INSURANCE
← 477-990 WORKERS’ COMPENSATION
← 973-440 INSURANCE CONSULTANT SERVICES
REMARKS:
BY: OFFICIAL OF FIRM
TITLE
NAME OF FIRM
DATE
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