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054.00.50 Appendix H. Continuing Education Providers Reporting Roster of Continuing Education C...

AR ADC 054.00.50 Appendix HArkansas Administrative Code

West's Arkansas Administrative Code
Title 054. Insurance Department
Division 00.
Rule 50. Continuing Education for Producers and Adjusters
Ark. Admin. Code 054.00.50 Appendix H
054.00.50 Appendix H. Continuing Education Providers Reporting Roster of Continuing Education Completion for Use with Rule 50
Currentness
1. Provider Name ______________________________
2. Provider Number ______________________________
3. Provider Contact Name _________________________
4. Phone Number ______________________________
5. Date of Roster Submission _________________________
6. CE Course Title ______________________________
7 License #
8 Name of Licensee Printed Name(use full legal name)
9 Signature of Licensee
10 Date of Completion
11 Course Number
12 Credit hrs
ARKANSAS INSURANCE DEPARTMENT
1200 WEST THIRD STREET
LITTLE ROCK AR 72201
PHONE: 501-371-2750
Instructions for Appendix H
Continuing Education Providers Reporting Roster For Use with Rule 50
Complete Items 1-12.
1. Provider Name ––– complete name of CE course provider
2. Provider Number ––– the number assigned to the provider by the Insurance Department
3. Provider Contact Name ––– the individual staff should contact for questions on the form
4. Phone Number ––– the provider's number staff should call for questions on the form
5. Date of Roster Submission ––– date the form is being sent to the Insurance Department; but in any event no later than twenty (20) days after the completion of the course
6. Course Title ––– the name of the course taken by the licensee
7. License number ––– licensee's number assigned by the Department
8. Name of licensee--print the name of the producer (full legal name)
9. Signature of licensee--the licensee must sign the roster, Appendix H
10. Date of completion ––– the date the course was completed by the licensee
11. Course Number ––– the number assigned by the Department to the course
12. Credit Hours ––– the hours credited for completion of the course when approved by the Department
If you should have any questions regarding this form, please contact the Department License Division at 501-371-2750; or email [email protected].

Credits

Amended Sept. 30, 2010.
Current with amendments received through May 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 054.00.50 Appendix H, AR ADC 054.00.50 Appendix H
End of Document