Idaho Continuing Education Course Application
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1EXHIBIT E – INDIVIDUAL APPLICATION
NO FEE REQUIRED
IDAHO CONTINUING EDUCATION COURSE APPLICATION
IDAHO DEPARTMENT OF INSURANCE RULE NO. 53
NOTE: EXHIBIT E FORM, TIMED COURSE OUTLINE AND PROOF OF COMPLETION MUST BE SUBMITTED
TO THE IDAHO DEPARTMENT OF INSURANCE
WITHIN 180 DAYS OF THE COURSE COMPLETION DATE.
NAME, LICENSE NUMBER, PHONE, EMAIL ADDRESS, MAILING ADDRESS OF INDIVIDUAL SUBMITTING THIS APPLICATION
NAME ____
____________________________________
IDAHO LICENSE NUMBER ______ __________________________
PHONE NUMBER ___________________________ ___________
EMAIL ADDRESS _________________
______
MAILING ADDRESS __________________________________________ CITY_____________________ STATE________ ZIP CODE__________
COURSE TITLE
DATE OF COMPLETION
LOCATION
CITY
INSTRUCTOR
COURSE CATEGORY:
LIFE
HEALTH
PROPERTY
CASUALTY
ETHICS
GENERAL
LTC
ADJUSTER
ANNUITIES SUITABILITY
METHOD OF INSTRUCTION (circle appropriate):
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
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: Courses submitted using the Exhibit E application must have a completion date that falls during the renewal
period in which it is submitted, and at least 30 days prior to the license expiration date. Idaho regulation does not
allow carry over of any CE credit from one renewal period to another.
Idaho Department of Insurance, P.O. Box 83720, Boise, Idaho 83720-0043
(Rev. 8/2013) (EX-B:DOC)
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