Cal. Code Regs. tit. 10 § 2105.18
| State of California | Department of Insurance |
| Prelicensing and Continuing Education Provider | |
| Stipulation to Maintain Records Outside of California | |
| 446-32 (Rev. 06/2006) |
Producer Licensing Bureau--Education Section
320 CAPITOL MALL
SACRAMENTO, CA 95814-4309
Information (916) 492-3064
APPLICATION
The undersigned, as provider director of a prelicensing or continuing education provider duly authorized by the California Department of Insurance, has requested the Commissioner's authorization to maintain provider records at a location outside of California.
STIPULATION
In consideration of the Commissioner's granting of authorization to maintain the records described in California Code of Regulations, sections 2105.7 and 2188.4, at a location outside of California, the undersigned provider director, on behalf of the duly authorized education provider, agrees to reimburse the California Department of Insurance for the expense of travel for the Commissioner's agent to conduct routine records examinations. Any refusal by a provider to reimburse the California Department of Insurance shall constitute grounds for automatic termination of the Commissioner's authorization to maintain records outside of the state, and may also be considered in any subsequent hearing on the rescission of provider status. This agreement will remain in force concurrent with the provider's certification period.
PROVIDER NUMBER: ______________________________
| PROVIDER NAME: | |
| (Print or type) | |
| PROVIDER DIRECTOR NAME: | |
| (Print or type) | |
| PROVIDER DIRECTOR SIGNATURE: | DATE: |
Cal. Code Regs. Tit. 10, § 2105.18
Note: Authority cited: Section 1812, Insurance Code. Reference: Section 1810.7, Insurance Code.