23 CAR pt. 18, Appendix A. Approval Forms

ARKANSAS INSURANCE DEPARTMENT Appendix A-1 Producer and Title Agent Continuing Education Course Approval Form (print in ink or type) Provider Name __________________________________________ Provider #: ________________________ Contact Person: ______________________________________ Contact Phone # ________________________ Contact Fax #: Contact e-mail Address: Course Title Will this course open to the public: ________ Yes _______ No Course Type: (Select One) Self Study (complete formula on appendix B) Class Room (attach a timed outline of the class presentation) Correspondence Seminar Teleconference Video/Audio/CD/DVD Distance Learning ______________ Special note: Hours awarded for self study course will be based on the formula on Appendix B. All self study courses must have a proctored exam. Course Field of Study (select only one) Topic: Hours Requested Hours Approved ____ Accident/Sickness/Health ____ Property/Casualty ____ Life ____ Personal Lines ____ Ethics ____ Annuities ____ Variable Products ____ Flood ____ Workers Compensation Property (only) Casualty (only) ____ Title Title Ethics Signature of Provider Representative Date: ___________________ Provider Representative's Phone Number : Department Use Only: Approved by: __________________________________________________ Date: Declined by: Date: Course Number Assigned Department Use Only: Approved by: _________________________________________________ Date: Declined by: Date: Course Number Assigned ARKANSAS INSURANCE DEPARTMENT Appendix A-2 Adjuster Continuing Education Course Approval Form (print in ink or type) Provider Name Provider #: Contact Person: _____________________________________ Contact Phone # _________________________ Contact Fax #: ___________________________ Contact e-mail Address: _____________________________ Course Title Will this course open to the public: Yes No Course Type: (Select One) Self Study (complete formula on appendix B) Class Room (attach a timed outline of the class presentation) Correspondence Seminar Teleconference Video/Audio/CD/DVD _______________________ Distance Learning ______________ Special note: Hours awarded for self study course will be based on the formula on Appendix B. All self study courses must have a proctored exam. Course Field of Study (select only one) Topic: Hours Requested Hours Approved _Property/Casualty __ _Ethics __ _Workers Compensation __ _Property (only) ____ Casualty (only) Signature of Provider Representative Date: Provider Representative's Phone Number Department Use Only: Approved by: _________________________________________________ Date: Declined by: Date: Course Number Assigned ARKANSAS INSURANCE DEPARTMENT Appendix A-3 Annuity Suitability Training Course Approval Form (print in ink or type) Signature of Provider Representative Date: Provider Representative's Phone Number Provider Name Provider #: Will this course be open to the public: Yes No Course Type: (Select One) Self Study (complete formula on appendix B) presentation) Correspondence Teleconference - Video/Audio/CD/DVD __________ Class Room (attach a timed outline of the class Seminar Distance Learning _________________ Contact Person: ________________________________________ Contact Phone # ______________________ Contact Fax #: ________________________________ Contact e-mail Address: Course Title Special note: Hours awarded for self study course will be based on the formula on Appendix B. All self study courses must have a proctored exam.