23 CAR pt. 18, Appendix A
Appendix A-1 Producer and Title Agent Continuing Education Course Approval Form
(print in ink or type)
Provider Name ____ Provider #: ______
Contact Person: ____ Contact Phone # ______
Contact Fax #:
Contact e-mail Address:
Course
Title
Will this course open to the public: Yes No
Course Type: (Select One)
Self Study (complete formula on appendix B)
Class Room (attach a timed outline of the class presentation)
Correspondence
Seminar
Teleconference
Video/Audio/CD/DVD
Distance Learning ________
Special note: Hours awarded for self study course will be based on the formula on Appendix B. All self study courses must have a proctored exam.
Course Field of Study (select only one)
Topic:
Hours Requested
Hours Approved
☐ Accident/Sickness/Health
☐ Property/Casualty
☐ Life
☐ Personal Lines
☐ Ethics
☐ Annuities
☐ Variable Products
☐ Flood
☐ Workers Compensation
☐ Property (only)
☐ Casualty (only)
☐ Title
☐ Title Ethics
Signature of Provider Representative
Date: ____ Provider Representative's Phone Number : ______
Department Use Only: ________
Approved by: ________
Date: ________
Declined by:
Date: ________
Course Number Assigned ________
Appendix A-2 Adjuster Continuing Education Course Approval Form
(print in ink or type)
Provider Name ____ Provider #: ______
Contact Person: ____ Contact Phone # ______
Contact Fax #: ____ Contact e-mail Address: ______
Course Title
Will this course open to the public: Yes No
Course Type: (Select One)
Self Study (complete formula on appendix B) Class Room (attach a timed outline of the class presentation)
Correspondence Seminar
Teleconference
Video/Audio/CD/DVD ____ Distance Learning ______
Special note: Hours awarded for self study course will be based on the formula on Appendix B. All self study courses must have a proctored exam.
Course Field of Study (select only one)
Topic: Hours Requested Hours Approved
☐ Property/Casualty
☐ Ethics
☐ Workers Compensation
☐ Property (only)
☐ Casualty (only)
Signature of Provider Representative
Date: ________
Provider Representative's Phone Number ________
Department Use Only:
Approved by: ____ Date: ______
Declined by: ________
Date: ________
Course Number Assigned ________
Appendix A-3 Annuity Suitability Training Course Approval Form
(print in ink or type)
Provider Name ____ Provider #: ______
Contact Person: ____ Contact Phone # ______
Contact Fax #: ________
Contact e-mail Address: ________
Course Title ________
Will this course be open to the public: ☐ Yes ☐ No
Course Type: (Select One)
Self Study (complete formula on appendix B) presentation)
Class Room (attach a timed outline of the class
Correspondence
Seminar
Teleconference -
Video/Audio/CD/DVD
Distance Learning
Special note: Hours awarded for self study course will be based on the formula on Appendix B. All self study courses must have a proctored exam.
Signature of Provider Representative ________
Date: ________
Provider Representative's Phone Number ________
Department Use Only:
Approved by: ____ Date: ______
Declined by: ________
Date: ________
Course Number Assigned