054.00.31 Appendix 3(B). Accident, Health, and Sickness for use with Rule 31
AR ADC 054.00.31 Appendix 3(B)Arkansas Administrative CodeEffective: February 7, 2016
Effective: February 7, 2016
Ark. Admin. Code 054.00.31 Appendix 3(B)
054.00.31 Appendix 3(B). Accident, Health, and Sickness for use with Rule 31
To: Arkansas Insurance Department
License Division
1200 West Third
Little Rock, AR 72201-1904
This is to certify that the following applicant has satisfactorily completed twenty (20) hours of instruction in the area of Accident, Health, and Sickness.
Applicant Name:
____________________________________________________________
Residence Address:
____________________________________________________________
Social Security No. & License No.:
_______________________________________________________
Date of Birth:
____________________________________________________________
Name of Approved Training Facility/Electronic Facility:
___________________________________
Date of Course Completion:
____________________________________________________________
Study Method of Course Completion (in classroom or electronic media or both). Classes were conducted on the following dates covering the following subject areas:
Subject Area | Date | No. of Hrs Completed | No. Hrs Classroom(“C”), Electronic(“E”) or Both(“B”) |
|---|---|---|---|
Introduction to Insurance (1 hr) | |||
State Insurance Laws and Rules (5 hrs) | |||
Health Insurance Policy Provisions (3 hrs) | |||
Disability Income Insurance (2 hrs) | |||
Medical Expense Insurance (1 hr) | |||
Medicare Supplement Insurance (1 hr) | |||
Long Term Care (2 hrs) | |||
Social Security and Medicare (2 hrs) | |||
Group Insurance (1 hr) | |||
Health Maintenance Organizations (1 hr) | |||
Ethics (1 hr) | |||
TOTAL NUMBER OF HRS COMPLETED |
For those applicants seeking an exemption from the five (5) hours on State Insurance Laws and Rules, please initial here: _____. Applicant certifies that the portion of study on State Insurance Laws and Rules for a total of five (5) hours was completed on __________(course date) _____, and is therefore not required to be completed in this certification.
We acknowledge that falsifying this statement will result in disciplinary action taken against us by the Arkansas Insurance Department.
______________________________ | ________________________________________ |
(Typed Name of Applicant) | (Typed Name of Instructor/Proctor) |
______________________________ | ________________________________________ |
(Signature of Applicant) | (Signature of Instructor/Proctor) |
______________________________ | ________________________________________ |
(Provider Name) | (Provider Number) |
______________________________ | ________________________________________ |
(Date Signed) | (Date Signed) |
Credits
Amended Feb. 7, 2016.
Current with amendments received through February 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 054.00.31 Appendix 3(B), AR ADC 054.00.31 Appendix 3(B)
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