Get Iowa Insurance Division Course Approval Application Form

Iowa Insurance Division Continuing Education Program Course Approval Application Please Print or Type. Photocopy as Needed* Provider Name Street Address City State Zip Email Address Course Title maximum of 40 characters Course Number Leave Blank Subject Area General Ethics Indexed Product Method Type select one Classroom Exact number of credits requested no 1/2 credits permitted Long-term Care Annuity Products Self-study include word count Is this course open to the public No Yes For classroom only How will this course be taught check all that apply Lecture Video/Teleconference Interactive Web-based Workshop Panel Discussion Other List the date starting time and location of the first course presentation* Attach a separate sheet of paper if there is more than one date and location* If unknown note tbd to be determined and note IAC Chapter 11 requires Within 30 days of course approval CE providers shall inform the division or its vendor as directed by the division of the dates and locations that the course will be offered* Failure to timely file the dates and locations will subject the CE provider to penalty and suspension or recission of course approval* Date Starting Time first presentation Phone Number City State and ZIP Code If needed additional dates and locations can still be added after approval is given by going to www. pearsonvue. com* List Name s and Qualifications of the Instructor s. Use a separate sheet of paper if needed* List names and sample signatures of persons authorized to sign the certificates of completion* Name Signature For all courses Attach a comprehensive course outline. Annotate the outline indicating for each section the number of minutes of instruction that will be offered* The total time of the class MUST also be included in the outline. Has the provider or any officer principal or instructor of the company had any disciplinary action taken since your last application for course approval in the state of Iowa I certify that the information on this form and all other supporting documentation accurately represents the course of and Iowa Administrative Rules. Please allow 30 days from date of receipt by Pearson VUE for processing* Print or Type Name of Provider Representative Make 55 fee payable to Pearson VUE/IA CE and mail form with the 55 fee to Pearson VUE Attn Iowa Ins CE Approval 62398 Collections Center Drive Chicago IL 60693-0623 The 55 fee represents an administrative expense and is therefore not refundable. Photocopy as Needed* Provider Name Street Address City State Zip Email Address Course Title maximum of 40 characters Course Number Leave Blank Subject Area General Ethics Indexed Product Method Type select one Classroom Exact number of credits requested no 1/2 credits permitted Long-term Care Annuity Products Self-study include word count Is this course open to the public No Yes For classroom only How will this course be taught check all that apply Lecture Video/Teleconference Interactive Web-based Workshop Panel Discussion Other List the date starting time and location of the first course presentation* Attach a separate sheet of paper if there is more than one date and location* If unknown note tbd to be determined and note IAC Chapter 11 requires Within 30 days of course approval CE providers shall inform the division or its vendor as directed by the division of the dates and locations that the course will be offered* Failure to timely file the dates and locations will subject the CE provider to penalty and suspension or recission of course approval* Date Starting Time first presentation Phone Number City State and ZIP Code If needed additional dates and locations can still be added after approval is given by going to www. pearsonvue. com* List Name s and Qualifications of the Instructor s. Use a separate sheet of paper if needed* List names and sample signatures of persons authorized to sign the certificates of completion* Name Signature For all courses Attach a comprehensive course outline.