ARKANSAS INSURANCE DEPARTMENT

APPENDIX F REQUEST FOR

EXEMPTION FOR USE

WITH 23 CAR pt. 18

TO: ARKANSAS INSURANCE DEPARTMENT

Licensing Division

1200 West Third Street

Little Rock, AR 72201-1904

Under Arkansas Code §23-64-302(3) and (4) as amended, I held an Arkansas producer license before July 1, 2003, and now am requesting the following exemption(s) Continuing Education Hours:

_ At least sixty (60) years of age. Date of Birth _. (Attach copy of birth certificate or other document evidencing date of birth.)

_ Have held a license as an agent, broker, producer for a period of fifteen (15) consecutive years. Date first licensed _

I certify that the information set out above is true and correct to the best of my knowledge and belief.

Signature

Name (Print or Type)

Arkansas License Number(s)

Street Address

Telephone Number

City, State, Zip

E-MAIL ADDRESS:

Subscribed and sworn to or affirmed before me a notary public in and for the State of _ on this _ day of ____, 20__

(Notary seal)

Notary Public

My Commission expires