Form Wh14 - Request For Continuing Education Certification - Health Insurance Wbt - 2015

Request for Continuing Education Certification

Health Insurance WBT

Date of Exam______________________

/

/

Name (as it appears on your license):

Date of Birth:

(

)

Company Name:

Office Phone :

Email:

 Office

Mailing Address:

check one:

 Home

City / State / Zip:

FILING FEES Credit Card Information

AmEx 

MC 

Visa 

Discover 

Name on Card________________________________________________________________________________________

Card Number: ________________________________________________________________________________________ Exp. Date _______/_____

A.

State Fees: CE PROCESSING MAY BE DELAYED IF STATE FEES ARE NOT INCLUDED WITH THIS FORM.

Check here if a check will be mailed for state fees

B.

Resident State Only: Your home state has a continuing education law and a reciprocal agreement with your non-resident state. You will not be

issued additional certificates. Please contact the Licensing Dept. in your non-resident state(s) to determine the documentation required to renew

your non-resident license.

C.

Late Fee: Turn in this completed form with your affidavit within 5 days to avoid the $20.00 late fee.

D.

Rush Fees: A $25 fee is required for rush processing. An additional $15 fee is required for overnight service.

Make checks for all fees (state, late, rush, and/or overnight) payable to: The National Alliance. Submit payment with this form. Please mail late request forms and appropriate fee(s) to:

THE NATIONAL ALLIANCE  ATTN: CONTINUING EDUCATION DEPT  PO BOX 27027  AUSTIN TX 78755-2027

Resident State

Resident State

 NPN

 NPN

Montana

Alabama

 State Fee $4

State Fee $4

 NPN

 NPN

Alaska

Nebraska

 State Fee $4

State Fee $4

 License #

 License #

Nevada

Arizona

 NPN

State Fee $4

Arkansas

 Agent License #

 Agent State Fee $4

New Hampshire

 ADJ State Fee $4

State Fee $4

 License #

California

 License #

 License #

New Jersey

Colorado

 License #

 License #

New Mexico

Connecticut

 License #

New York

State Fee $3.75

 NPN

 NPN

North Carolina

Delaware

State Fee $4

State Fee $6.60

 NPN

 NPN

North Dakota

DC

State Fee $4

State Fee $4

 Agent License #

 NPN#

Florida

Ohio

 License #

State Fee $4

Georgia

 Entity #

Hawaii

 Agent License #

Oklahoma

NPN#

Oregon

 License #

Idaho

State Fee $4

State Fee $4

 License #

Pennsylvania

 NPN

Illinois

State Fee $5.00

State Fee $2.00

 NPN

Puerto Rico

 License #

Indiana

State Fee $4

State Fee $4

 NPN

Rhode Island

 NPN

Iowa

State Fee $4

State Fee $4

 License #

South Carolina

 NPN

Kansas

 License #

South Dakota

State Fee $4

State Fee $4

 License

Kentucky

 NPN

Tennessee

 License #

Louisiana

State Fee $4

 License #

Maine

 License #

Texas

 License #

Maryland

State Fee $3

State Fee $4

 License #

Utah

 License #

Massachusetts

State Fee $4

State Fee $2

 License #

Vermont

 System ID#

Michigan

State Fee $6

State Fee $4

 License #

Virginia

 License #

Minnesota

 License #

Washington

 Agent License #

Mississippi

 NPN #

West Virginia

State Fee $4

State Fee $6

 NPN State Fee $4

Missouri

 License #

Wisconsin

 License #

Wyoming

State Fee $4

I understand to receive State CE credit; I must pass the proctor exam and submit this CE form along with any applicable state fees.

___________________________________________________________

___________________________________

Date

Your Signature

WH14 REV 06.5.2015

Check here if you do not need this course filed for CE.