Exhibit A - Idaho Continuing Education Course Application
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1EXHIBIT A
IDAHO CONTINUING EDUCATION COURSE APPLICATION
IDAHO DEPARTMENT OF INSURANCE RULE NO. 53
NAME AND ADDRESS OF SPONSOR SUBMITTING COURSE
NAME AND TELEPHONE NUMBER OF CONTACT PERSON
PROVIDER NAME____________________________________________ FEDERAL TAX ID# (REQUIRED)______________________________
CONTACT PERSON__________________________________ _______ EMAIL ADDRESS OR CONTACT PERSON________________________
PHONE NUMBER___________________________ ________________ FAX NUMBER_______________________________________________
MAILING ADDRESS__________________________________________ CITY_____________________ STATE________ ZIP CODE__________
COURSE TITLE
DATE OF COURSE
LOCATION
CITY
INSTRUCTOR
(IF INSTRUCTOR IS NOT PREVIOUSLY APPROVED ATTACH BIO)
COURSE CATEGORY: LIFE
HEALTH
PROPERTY
CASUALTY
ETHICS
GENERAL
LTC
ADJUSTER
ANNUITIES SUITABILITY
YES
NO
IS THIS COURSE OPEN TO THE PUBLIC?
IF THIS COURSE IS A RENEWAL – COURSE NUMBER
EXPIRATION DATE
METHOD OF INSTRUCTION:
Classroom (contact): Seminar/Workshop
Webinar
Teleconference
Other
Self-Study (non-contact): Correspondence
Online training
Video/Audio/CD/DVD
Requested number of hours for this course ________
METHOD OF DETERMINING SATISFACTORY COMPLETION:
Examination
Attendance
Report
Other
NAMES AND SIGNATURES OF AUTHORIZED REPRESENTATIVES TO SIGN CERTIFICATE OF COMPLETION:
Name (Type or Print)
Signature
Name (Type or Print)
Signature
FOR DEPARTMENT USE ONLY
Date Reviewed
Approved Hours
__________
( ) Approved hours/course type changed from the previous approval
Course NOT approved for the following reason(s):
___________
( ) Sales/Marketing Oriented
( ) Does Not Relate to Insurance
( ) Self-Motivational
( ) Computer Science
( ) Other
Idaho Course Number:
Signature:
NOTE: Exhibit A form and detailed/timed outline or agenda must both be submitted to the Idaho Department of Insurance
along with $25 per course processing fee
Idaho Department of Insurance, P.O. Box 83720, Boise, Idaho 83720-0043
(Rev. 8/2013) (EX-A:DOC)
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