Cal. Code Regs. tit. 10 § 2105.19

Current through Register 2024 Notice Reg. No. 50, December 13, 2024

Section 2105.19 - Provider Roster

State of California	Department of Insurance
Provider Roster
446-13 (Rev. 06/2006)

Producer Licensing Bureau--Education Section

320 CAPITOL MALL

SACRAMENTO, CA 95814-4309

Information (916) 492-3064

www.insurance.ca.gov

Important:. This form must be submitted to the California Department of Insurance (CDI) within 10 days following the completion of the prelicensing course and 30 days following the completion of the continuing education or training course. Late rosters may not be accepted.Items marked with an asterisk (*) are not required for non-contact courses.

Pre-licensing Course:			[] Continuing Education Course: []
Contact course: []			Non-Contact course: []*
Provider ID #:	Provider Name:
Course ID #:	Credit Hours:						Course Name:
*Course Start Date:			*Beginning Time:			*End Time:	Completion Date:
						Military time (i.e. 1300 = 1:00 P.M.)
*Class location:
	Street Address						Suite/Room
	City					State	Zip Code

The Department requests disclosure of a student's social security number pursuant to Insurance Code Sections 1749, 1749.2, 1749.3, 1749.31, 1749.4, 1749.5, 1749.7, and 1810.7 and California Code of Regulations, Title 10, Chapter 5, Section 2105.10 (b) (1) through (7) and 2188.5 (b)(1). This information is requested so that the Department can properly identify and assign credit to students who have completed prelicensing or continuing education courses. While a student's disclosure of his or her social security number here is not mandatory, any failure to provide this information may delay or otherwise impede the Department in assigning credit for the completion of such courses to the appropriate students.

ALL ENTRIES MUST BE TYPED.

#	Social Security Number	Licensee Name: Last, First M.I.	Individual License #
1.
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15.
Please use backside for additional names.

Certification

I have reviewed this Provider Roster and the associated Course Attendance Records or examination information and certify to the best of my knowledge that the individuals listed here meet the requirements for credit.

		()
Original signature of Provider Director	Date	Phone
Printed Name of Provider Director

PROVIDER ROSTER (continued)

Page 2

All entries must be typed.

#	Social Security Number	Licensee Name: Last, First M.I.	Individual License #
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Cal. Code Regs. Tit. 10, § 2105.19

1. New section filed 8-20-2007; operative 9-19-2007 (Register 2007, No. 34).

Note: Authority cited: Section 1812, Insurance Code. Reference: Section 1810.7, Insurance Code.

1. New section filed 8-20-2007; operative 9-19-2007 (Register 2007, No. 34).
BASIC PRINCIPLES