Oklahoma Continuing Education Provider Packet

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Oklahoma Continuing Education Provider Packet Powered By Docstoc
					                        OKLAHOMA CONTINUING EDUCATION
                          CREDIT SUBMISSION CHECKLIST
                                                  (Rev. 11/04)

Please place your submission in the order listed below:

   1. CE-1 Provider Application Form:
        a. New providers submit completed application and $200.00 fee. (Annual renewal required)
        b. Update/changes to information at no cost.

   2. CE-2 Course Approval Request: Submit IN DUPLICATE for either agent/producer or adjuster. If
      applying for both, attach four (4) copies. Correspondence and Internet to be submitted separately.

   3. Course Description with objective statement.

   4. Classroom or Seminar
         a. Detailed outline of course with time breakdown (15 to 30 minute increments).
         b. Each page of outline sub-totaled.
         c. Total time matches or exceeds hours requested for credit

   5. Correspondence and Internet (Submit as separate courses)
         a. Copy of Table of Contents
         b. Copy of examination
         c. Course Material Content (See below)

   6. Course Material Content (Required to be submitted in hard copy format)
         a. Workbooks
         b. Manuals
         c. Overheads or Powerpoint Presentations
         d. Policies
         e. Handouts
         f. Promotional Material
         g. Any additional information used by instructor or material given to the agent/adjuster.

   7. CE-3 Instructor Qualification Form and resume for each instructor not approved for your provider.
        a. Instructors are approved for each individual provider, not for all providers.

   8. Copy of Certificate of Course Completion to be used other than the prescribed Oklahoma Insurance
      Department CE-5.
         a. Must be pre-approved by Oklahoma Insurance Department before use.

   9. A self-addressed, postage-paid envelope

   10. Materials must be in our office no later than the 25th of the month before meeting and PRIOR to course
       being offered. NO RETRO CREDIT GIVEN.
           a. The Agents and Adjuster Advisory Committee meeting is scheduled to meet the first Thursday of
              each month.
   11. Midwest Zone Application ONLY applies to agents. This does not apply to adjuster approvals.

        Forms are available on our website, www.oid.state.ok.us under the Agents Licensing Division.
                                                                                    (Rev. 11/04)

                           Oklahoma Insurance Commissioner
                                       P.O. Box 53408
                               Oklahoma City, OK 73152-3408
                             (405) 521-3916 Fax (405) 522-3642

                                  Continuing Education
                      For (specify): ( ) Agents/Producers ( ) Adjusters

                               PROVIDER APPLICATION
                ( ) New       ( ) Update       ( ) Reinstatement/Late Renewal

Provider Name: _______________________________________________________________

Mailing Address: ______________________________________________________________

Telephone: ___________________________ Fax: __________________________________

Continuing Education Coordinator: _______________________________________________

Mailing Address: _____________________________________________________________

Telephone: ___________________________ Fax: __________________________________

E-mail Address _____________________________

Web Address _______________________________

Are you closed to the public? ( ) Yes      ( ) No

Is this a public funded institution? ( ) Yes ( ) No

For Department Use Only:

Check # ______________________ Received _____________________ Provider Number _______________
                                                                                                                      (Rev. 11/04)
                                   OKLAHOMA INSURANCE COMMISSIONER
                                                 P. O. Box 53408
                                         Oklahoma City, OK 73152-3408
                                       (405) 524-3916 Fax (405) 522-3642
 Provider # E_______                                                                                     Provider # A______
                                             COURSE APPROVAL REQUEST

 For: ( ) Agents                              Submit This Form in Duplicate                              For: ( ) Adjusters
Provider Name/Address: (Type or Use Label)                          Contact Information:
                                                                    Name: ______________________________________________
                                                                    Phone: ______________________________________________
                                                                    Fax: ________________________________________________
                                                                    E-mail: _____________________________________________

Course Title:______________________________________________________________________________
__________________ hr(s) requested including ________ ethics and _________ HCR and __________ Long Term Care
Lines Requested:                              Course Information:
    Agent/Producer            Adjuster         Method of Instruction                  Type
( ) Life               ( ) WC       ( ) Bonds ( ) Class              ( ) New             ( ) Closed to Public
( ) A/H                ( ) Prop     ( ) Veh   ( ) Correspondence     ( ) Revised         ( ) Open to Public
( ) Title              ( ) Cas                ( ) Internet only                          ( ) Given one time -
( ) P/C                ( ) Crop Hail                                                         Not offered again
Location: ___________________________________________________________________________________________________

Address, City, State: __________________________________________________________________________________________

( ) To be determined, you must file form CE-6 at least 14 days prior to course date.

Start time: __________ End time: __________ Date(s) of Course: ____________________________________________________

Primary Instructor(s): _________________________________________________________________________________________
                        Instructors previously approved ( ) Yes ( ) No (If no, attach CE-3 and Resume)

Methods to Determine Completion:                                    If Corrs or Internet Course, complete this section:
( ) Sign in/out sheets                                              # Multiple Choice Exam Questions: ______________________
( ) Corrs or Internet Exams – monitored/closed text/affidavit       # Corrs Text Pages (complete pg’s 10-12 point font) _________
                                                                    # Internet Screens (2 screens = 1 page) ___________________
Type Name and Signature of Person authorized to sign Certificate of Completion (may add additional names on back):
_______________________________________________ ________________________________________________
Submitted by: (typed or printed name)                        Signature
For Department Use Only:                                     Date Reviewed _________________ By _____________

__________ Hr(s) approved including __________ Ethics __________ HCR __________ LTC

   Course approval will expire __________________without further notice and must receive new approval prior to
offering for credit.

   Approval withdrawn for course # _____________________ effective ______________________________________

__________ Hr(s) NOT approved for the following reason(s):
( ) Company/Product Specific ( ) Sales/Marketing Oriented ( ) Prospecting ( ) Too Basic ( ) Does Not Relate
( ) Self-Motivational ( ) Other: ___________________________________________________________________

Oklahoma Course Certification Number:                                  Signature:
                                                                                                         (Rev. 11/04)
                                 OKLAHOMA INSURANCE COMMISSIONER
                                               P. O. Box 53408
                                       Oklahoma City, OK 73152-3408
                                     (405) 521-3916 Fax (405) 522-3642


           This form must be completed and submitted for all new instructors 14 days prior to course date.

( ) For confirmation, a copy of this form and a self-addressed, stamped envelope must be

                                          INSTRUCTOR INFORMATION

Instructor Name:                                           Social Security Number :

Address:                                                   Sponsoring Entity:                   Provider Number:

City, State, Zip:                                          Instructor Signature and Date:

Please submit a resume indicating related-education and employment with this application.

I have the following qualification(s) in the subject being taught by the required attached resume:

( ) Three (3) years of recent experience

( ) A degree related to the subject

( ) Two (2) years of recent experience and 12 hours of college &/or vo-tech school credit hours

Have you ever taught an insurance course before? ( ) Yes         (   ) No

If yes, last date and place _____________________________________________________________________

I certify that the information contained in this application is correct and that I will notify the Oklahoma
Insurance Department within 10 days of any changes in the information contained herein.

Coordinator Signature: ______________________________________ Date: __________________________

For Department Use Only:

(   ) Approved      (   ) Rejected   (   ) Deferred ________________________________________________________

Signature: ____________________________________________________________ Date: ______________________
                                                                                                      (Rev. 11/04)

                              OKLAHOMA INSURANCE COMMISSIONER
                                            P. O. Box 53408
                                    Oklahoma City, OK 73152-3408
                                  (405) 521-3916 Fax (405) 522-3642

                                    ATTENDANCE REPORT FORM
                                                                                           Page _____ of _____

This information must be typed or legibly printed and received in the Department within ten (10) business
days of course completion. Correspondence courses shall be filed by the 5th and 20th of each month. A
separate CE-4 form shall be prepared for each individual course number*. Your own format may be submitted
but must list the required information indicated below. Attach additional forms as necessary.

Provider Name ____________________________________________________________________________

Address __________________________________________________________________________________

Contact _______________________________________ Phone ( _____ ) _____________________________

Course Title ______________________________________________________________________________

*If you are reporting only one person with multiple courses, you may use one reporting form.

Oklahoma Course Number(s)_________________________________________________________________

Date of Course                       Oklahoma License Number                       Licensee’s Name
(Chronological Order)                (Credit will not be given without
                                     Oklahoma License Number)

                                     PROVIDER’S AFFIDAVIT

I hereby certify that the above and foregoing is a timely and accurate report of continuing education to the
Oklahoma Insurance Department. The agents/producers or adjusters appearing on this report completed the
course and are entitled to continuing education credits as reflected above.

Authorized Signature _____________________________________ Date ___________________________
                                                                                                   (Rev. 11/04)

                             OKLAHOMA INSURANCE COMMISSIONER
                                           P. O. Box 53408
                                   Oklahoma City, OK 73152-3408
                                 (405) 521-3916 Fax (405) 522-3642

                                 CONTINUING EDUCATION
                           CERTIFICATE OF COURSE COMPLETION


The provider shall file your completed classroom course(s) with the Oklahoma Insurance Department
within ten (10) business days. Completed correspondence courses shall be filed by the provider on the 5th
and 20th of each month proving your successful course completion. 24 months must pass from completion
date before a course may be repeated. Excess credit hours will not be carried forward.

PLEASE KEEP THIS CERTIFICATE FOR YOUR RECORDS. Some providers may charge a fee to
furnish you with a duplicate form.

Licensee’s Name:                                                          Oklahoma License Number:


City, State, Zip:

Provider Name:

Course Title:                                           Course Number:

Number of Hours:            Number hours of Ethics      Number hours of HCR           Number hours of LTC
                            included:                   included:                     included:
Date Course Completed:                                  Location:

Coordinator’s Signature:                                                  Date:

                           Please verify that the information indicated is correct.
                                                                                                     (Rev. 11/04)

                               OKLAHOMA INSURANCE COMMISSIONER
                                             P. O. Box 53408
                                     Oklahoma City, OK 73152-3408
                                   (405) 521-3916 Fax (405) 522-3642

Provider Name: ____________________________________________________________________________

This notification is being filed with the Oklahoma Insurance Department at least 14 days in advance of the
beginning date of the approved course to confirm the time, location, date and instructor(s).

Title of Course: ___________________________________________________________________________

Oklahoma Approved Course Number: _________________________________________________________

Is this course closed to the public? (   ) Yes   (   ) No

Date to be held: ________________________________ Time: ____________________________________

Location (Address/City/State): _______________________________________________________________

Instructor(s) for course:                                                         Previously Approved?

_______________________________________________________                           (   ) Yes    (   ) No

_______________________________________________________                           (   ) Yes    (   ) No

_______________________________________________________                           (   ) Yes    (   ) No

If no, attach a completed CE-3 form with resume.

Submitted by: ________________________________________ Title: _______________________________

Organization: ________________________________________ Date: _______________________________

I will notify the Oklahoma Insurance Department on form CE-4 within ten (10) business days of all students
who complete this course.


Telephone number: _________________________________ Fax Number: ___________________________
                                                                                                         (Rev. 11/04)

                   Midwest Zone Standard Continuing Education Filing Form
Provider Name _____________________________________________________________________________________

Contact Person _____________________________________________________________________________________

Address ___________________________________________________________________________________________

City ___________________________________________ State _________________ Zip Code ____________________

Federal Tax ID No. _______________________________ Telephone No. _____________________________________

Course Title _______________________________________________________________________________________

Attached is an (approved application) (course approval letter) from my resident State. This course was approved for
credit in the following category:

( ) Life                                ( ) Health                      ( ) Property/Casualty

Please file this course for approval in the State of __________________________________________________________

My Oklahoma Provider Identification number is _________________________________________________________

Enclosed is the registration/approval fee of $ _____________________________________________________________

Instructor Name(s) ________________________________________ SSN _____________________________________

Is the course open to the public? ( ) Yes ( ) No
Dates and locations where the course will be offered:


If this course is being filed for approval in California, Indiana, Kentucky, Michigan, Missouri, New York, North
Carolina, Ohio, Oklahoma, Utah or Wisconsin a timed outline of the approved course must be attached to this

Instructor names are only required if this course is being filed for approval in Oklahoma, Wisconsin, Nebraska, South
Dakota, Kentucky or North Carolina. Instructors names and SSNs need not be listed on this form if the information is
contained in the enclosed approval application/course approval letter.
Department Use Only

1. Course approved for _____________ credits of:
   ( ) life  ( ) health       ( ) ethics      ( ) property/casualty     ( ) health care reform    ( ) long-term care

by __________________________________________Date ________________________________________

of the Oklahoma Department of Insurance ● Course Number ________________________________________

This course approval will expire ___________________________ without further notification.

2. Course disapproved. Comment _____________________________________________________________________