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Request for Continuing Education Certification

DATE of EXAM: _______________________________________

Legal & Ethical Requirements of Insurance Professionals

_______________

Name

Date of Birth:

(as it appears on your license):

Company Name:

Office Phone: (

)

Email:

Mailing Address:

check one:

 Home or Office

City, State, Zip:

AmEx 

MC 

Visa 

Discover 

FILING FEES:

Credit Card Information:

______________________________________________________________________

Name on Card_

______________________________________________________________________

Card Number: _

Exp. Date _______/_____

State Fees: CE PROCESSING MAY BE DELAYED IF STATE FEES ARE NOT INCLUDED WITH THIS FORM.

Check here if a check will be mailed for state fees

Resident State Only: Your home state has a continuing education law and a reciprocal agreement with your non-resident state. You will not be issued additional

certificates. Please contact the Licensing Dept. in your non-resident state(s) to determine the documentation required to renew your non-resident license.

Late Fee: Turn in this completed form with your affidavit within 5 days to avoid the $20.00 late fee.

Rush Fees: A $25 fee is required for rush processing of CE.

Make checks for all fees (state, late, rush, and/or overnight) payable to: The National Alliance. Submit payment with this form. Please mail late request forms and

THE NATIONAL ALLIANCE  ATTN: CONTINUING EDUCATION DEPT  PO BOX 27027  AUSTIN, TX 78755-2027

appropriate fee(s) to:

Resident State

 NPN

Alabama

Montana

 State Fee $4

State Fee $4

 NPN

NPN#

Alaska

Nebraska

State Fee $4

 License #

Arizona

Nevada

 NPN

State Fee $4

Arkansas

 Agent State Fee $4

 NPN

New Hampshire

 ADJ State Fee $4

 Agent State Fee $4

 Public ADJ State Fee $4

 License #

California

 Multi ADJ State Fee $4

 License #

Colorado

 Workers ADJ State Fee $4

 License #

Connecticut

 License #

New Jersey

State Fee $3.75

 License #

 NPN

New Mexico

Delaware

 License #

New York

State Fee $4

 NPN

North Carolina

District of Columbia

State Fee $6.60

State Fee $4

 NPN

 Agent License #

North Dakota

Florida

 ADJ License#

State Fee $4

 NPN

 License #

Ohio

Georgia

State Fee $4

 Entity #

Hawaii

 Agent License#

 License #

Oklahoma

Idaho

 ADJ License#

State Fee $4

NPN#

Oregon

 NPN

Illinois

State Fee $4

 License #

Indiana

 License #

Pennsylvania

State Fee $4

State Fee $5.00

 NPN

Iowa

 NPN

Rhode Island

State Fee $4

 NPN

Kansas

 License #

South Carolina

State Fee $4

 License #

South Dakota

 License #

Kentucky

State Fee $4

 License #

Louisiana

 NPN

Tennessee

 ADJ License#

State Fee $4

 License #

Maine

 License #

Texas

 License #

Maryland

State Fee $3

 License #

Utah

 License #

Massachusetts

State Fee $4

State Fee $3

 License #

Vermont

 System ID#

Michigan

State Fee $9

State Fee $4

 License #

Virginia

 License #

Minnesota

 OIC #

Washington

 License #

Mississippi

 NPN #

West Virginia

 ADJ License#

State Fee $6

State Fee $4

 License #

Wisconsin

 NPN

Missouri

 License #

Wyoming

State Fee $4

I understand to receive State CE credit; I must pass the proctor exam and submit this CE form along with any applicable state fees.

_____________________________________________________________________________________

______________________________________

Your Signature

Date WEIP rev 06.5.2015

Check here if you do not need this course filed for CE.

Form Weip - Request For Continuing Education Certification - Legal & Ethical Requirements Of Insurance Professionals - 2015

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