California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 1 - Production of Insurance › Article 2.1 - Bail Education › Section 2105.14 - Prelicensing/Continuing Education Program Instructor Qualification

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
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
www.insurance.ca.gov
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
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