ARKANSAS INSURANCE DEPARTMENT

APPENDIX G

CORRESPONDENCE COURSE

CERTIFICATION OF COMPLETION AND PROCTOR AFFIDAVIT

FOR USE WITH RULE 50

 

All Correspondence Courses must have a proctored exam to be valid.    Form must be typed or printed.

LICENSEE’S INFORMATION

Name of Licensee: _______________________________________________________

Licensee’s License # ______________________________________

Resident Address: ________________________________________________________

                                    Street or P.O. Box                                    City or State                                             Zip

Business Phone # ____________________________________

Producer Signature___________________________  Date _______________________

 

PROCTOR INFORMATION:

Proctors Name: ______________________________________________________

Proctors Address: ____________________________________________________

Proctors Phone Number: _______________________________________________

Proctors Driver’s License # ______________________ State of Issue  __________

Start Time of Exam ____________ End Time of Exam ______________

Date of Completion of Examination_______________________________________

Location of Examination ________________________________________________


ATTESTATION:

I do hereby solemnly attest that I proctored the above correspondence examination provided to the above name licensee and that the examination was provided as instructed by the Course Provider.  I assure the Commissioner that no attendee was permitted to use study materials or have assistance during the exam.  Further, I am not part of, or aware of any efforts to circumvent the requirements of the proctored examination, and I have no special interest to ensure the licensee passes the examination.  I understand that this affidavit is provided under oath or affirmation, and that false information shall be grounds for possible Arkansas Insurance Code or Rule penalties.

 

__________________________________                _________________________

Signature of Proctor                                                                Date


Once Licensee has tested and Proctor has completed form—Provider completes and sends to Department

CONTINUING EDUCATION PROVIDER INFORMATION (Completed by Provider only)

Course Name ______________________________________ Course # ______________

Provider Name            C.E.I.S. (Continuing Education Insurance School       Provider’s #               1391               

 

Signature of Provider Responsible Contact        Date:_________________

 

 

Instructions:

This completed form is to be returned to the Provider of the Course.  No credit for the course will be given until the Provider has received this document.  The Provider will provide a copy of this form to the Insurance Department by electronic media.