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054.00.50 Appendix C. Continuing Education Provider Application

AR ADC 054.00.50 Appendix CArkansas Administrative CodeEffective: February 7, 2016

West's Arkansas Administrative Code
Title 054. Insurance Department
Division 00.
Rule 50. Continuing Education for Producers and Adjusters
Effective: February 7, 2016
Ark. Admin. Code 054.00.50 Appendix C
054.00.50 Appendix C. Continuing Education Provider Application
Currentness
Name of Provider: ____________________________________________________________
Address:
_______________________________________________________
Street or P.O. Box
City
State
Zip
Phone Number: ______________________________ Fax __________# ________________________________________
Name of Contact Person #1 ____________________________________________________________
Contact Person Phone # ______________________________ Fax # _________________________
Contact Person E-mail: ____________________________________________________________
Name of Contact Person #2 ____________________________________________________________
Contact Person Phone # ______________________________ Fax # _________________________
Contact Person E-mail: ____________________________________________________________
What other States are you approved as a Provider of Continuing Education:
 
____________________________________________________________
 
____________________________________________________________
List Representatives Authorized to Sign Certificates for Provider:
_________________________
____________________
_________________________
Name
Title
Signature
_________________________
____________________
_________________________
Name
Title
Signature
_________________________
____________________
_________________________
Name
Title
Signature
Type of Courses Provider Will Offer: (check all that apply)
_____ Producer (agent/broker) _____ Title _____ Adjuster
Signed ___________________________________
Printed Name ______________________________
Title ___________________________________
Dated ___________________________________
**************THIS FORM IS TO BE SUBMITTED WITH A REGISTRATION FEE OF $100**************
For Department Use:
Fee Received:_______________ Check or Route Slip: _______________
Approved by ________________________________________ Date:_______________
Disapproved by ___________________________________ Date:_______________

Credits

Amended Sept. 30, 2010; Feb. 7, 2016.
Current with amendments received through February 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 054.00.50 Appendix C, AR ADC 054.00.50 Appendix C
End of Document