Cal. Code Regs. tit. 10 § 2105.14
| State of California | Department of Insurance |
| Prelicensing/Continuing Education Program | |
| Instructor Qualification Form | |
| 446-4 (Rev. 06/2006) |
___________________________
Producer Licensing Bureau--Education Section
320 CAPITOL MALL
SACRAMENTO, CA 95814-4309
Information (916) 492-3064
INSTRUCTIONS
* This form must be completed by each proposed instructor, lecturer, moderator or person conducting a classroom course, seminar, workshop, conference, etc.
* Type or print clearly in ink.
* Provider Director must verify the information provided by the instructor.
* DO NOT SUBMIT THIS FORM TO THE DEPARTMENT. PLEASE RETAIN THIS FORM IN YOUR FILES FOR FIVE YEARS.
* Attach additional sheets if more space is needed to answer questions.
| Provider Number: ___________________________ | Date: | ___________________________ |
| Provider Name: ___________________________ | Telephone: | ___________________________ |
| Address: ___________________________ | |||
| Street | City | State | Zip Code |
| Instructor Name: ___________________________ | Residence Phone: ___________________________ | ||
| Residence Address: ___________________________ | |||
| Street | City | State | Zip Code |
List the course titles and course numbers to be taught:
| Course Title | Course Number |
___________________________
___________________________
Describe your experience (3 years within the last 5 years) in the course subject matter:
___________________________
___________________________
___________________________
If you hold or have ever held an insurance license, complete the following:
| License Type | License Number | State or Province | Dates License Held | ||
| From | To |
If you have a college degree in the subject matter being taught, complete the following:
| Name of College or University | Course of Study | Degree | Date Completed |
___________________________
Please indicate if you hold a recognized professional insurance designation and the date earned:
| ____LUTC | ____ CLU | ____ AAI | ____ CPCU | ____ CIC | ___ Other: ____________________________ |
If you hold a recognized professional credential in the subject matter being taught, complete the following:
| Type of Credential | Credential Number | Date Earned | State or Province Issued | ||||
| ___________________________ | ___________________________ | ___________________________ | ___________________________ | ||||
Have you ever been an instructor for another prelicensing or continuing education provider?
__________YES __________ NO If YES, list the provider names, dates and reasons for leaving:
___________________________
Have you been the subject of any administrative agency disciplinary action? For the purpose of this question, administrative agency disciplinary action includes but is not limited to: having any professional, vocational or business license denied, suspended, placed on probation, restricted or revoked, or any fine imposed; withdrawing any application or surrendering any license to avoid disciplinary action; being issued a cease and desist order or its equivalent; being the subject of a conservation, liquidation, rehabilitation or receivership order. __________YES __________ NO
| Have you ever been convicted of a crime? | _____YES | _____ NO |
"Crime" includes a felony or misdemeanor and military offenses. "Convicted" includes, but is not limited to, having been found guilty by verdict of a judge or jury, having entered a plea of guilty or nolo contendere, having had any charge dismissed, expunged or plea withdrawn pursuant to Penal Code Section 1203.4, or having been given probation, a suspended sentence or a fine. You may exclude traffic citations and juvenile offenses.
< IMPORTANT NOTE: If the answer is "YES" to either of the above two questions, attach a detailed statement, signed by you, listing the events which led to the charges (dates and places). If the matter was heard in court, attach copies CERTIFIED BY THE COURT of the Criminal Complaint and the Sentencing Minute Order showing the final plea, judgment and sentence. If any disciplinary action was taken by an administrative agency, attach a certified copy of the action.
INSTRUCTOR CERTIFICATION
I certify under penalty of perjury that the information contained in this application is true and correct and that nothing has been withheld which would influence a complete evaluation of my qualifications and conduct as an instructor.
I understand that this completed application will be maintained by the provider and made available to the commissioner as requested.
| ___________________________ | |
| Original Signature of Instructor | Date |
PROVIDER VERIFICATION
I certify under penalty of perjury that I have reviewed and verified the qualifications of the instructor named above. To the best of my knowledge and belief, this person meets all of the checked qualifications per sections 2105.4 or 2188.1 of Tit. 10 California Code of Regulations. Note: Bail education instructors must satisfy the "three years experience" qualification. Other education instructors must satisfy at least one of the listed qualifications.
| _____ | Three years experience within the last five years in the course subject matter, which experience may include holding an appropriate insurance license for the subject being taught. |
| _____ | Possession of a college degree in the subject matter being taught. |
| _____ | Possession of a related recognized professional designation in the subject matter being taught. |
| _____ | Possession of a related recognized professional credential in the subject matter being taught. |
DO NOT SUBMIT THIS FORM TO THE DEPARTMENT. PLEASE RETAIN THIS FORM IN YOUR FILES FOR REVIEW DURING A PROVIDER AUDIT.
___________________________
Original Signature of Provider Director Date
___________________________
Printed Name of Provider Director
Cal. Code Regs. Tit. 10, § 2105.14
Note: Authority cited: Section 1812, Insurance Code. Reference: Section 1810.7, Insurance Code