Form Fint05 - Application For Licensee Exemption Or Extension
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1FINT05 | 0316
APPLICATION FOR LICENSEE EXEMPTION OR EXTENSION
PRINT OR TYPE- see instructions at the bottom of this page.
1. Licensee’s Name: _____________________________________________________________________
2. Licensee’s Mail Address: ________________________________________________________________
Street Address
_____________________________________________________________________
City
State
Zip Code
3. Licensee’s SSN: ____________________________ 4. Licensee’s email: _______________________________
5. Check one box:
This application is for an extension of time to complete continuing education due to:
Illness or medical disability
Circumstances not related to business beyond the licensee’s control
Active military duty in a combat theater
Documentation required as applies:
a) Statement of the exact nature of the illness, medical disability or other extenuating circumstances
beyond the control of the licensee that have prevented or will prevent the licensee from completing the
required hours within the two year reporting period.
b) Evidence in the form of medical reports from attending physician or evidence through insurance claims
regarding the illness or medical disability of the licensee and other documentation as determined
regarding circumstances beyond the control of the licensee.
c) Assessment of the condition of the licensee whether it is temporary, permanent or unknown.
d) Statement as to whether the licensee will or will not be able to perform activities including any acts of
an agent or adjuster.
e) Estimated date when the licensee will be able to perform any activities including any acts of an agent or
adjuster in accordance with the medical reports or other documents pertaining to circumstances
beyond the control of the licensee
f) Copy of order to active duty, expected duration of assignment, and any other information licensee
thinks will assist the department.
6. Signature of licensee: __________________________________________________ Date: _________________
NOTICE ABOUT CERTAIN INFORMATION LAWS AND PRACTICES
With few exceptions, you are entitled to be informed about the information that the Texas Department of Insurance (TDI) collects about you.
Under sections 552.021 and 552.023 of the Texas Government Code, you have a right to review or receive copies of information about yourself,
including private information. However, TDI may withhold information for reasons other than to protect your right to privacy. Under section
559.004 of the Texas Government Code, you are entitled to request that TDI correct information that TDI has about you that is incorrect. For
more information about the procedure and costs for obtaining information from TDI or about the procedure for correcting information kept by
TDI, please contact the Agency Counsel Section of TDI’s General Counsel Division at (512) 676-6551 or visit the Corrections Procedure section of
TDI’s website at
INSTRUCTIONS
Print or type information requested in items 1, 2, 3, 4. Make sure licensee’s name is given exactly as it is on the license.
Extension of time to do continuing education: The licensee may request an extension of time or a waiver, if prevented
from doing the required hours within the two year renewal cycle by illness, medical disability, non-business
extenuating circumstances beyond the licensee’s control, or because of active military service in a combat theater.
Documentation required is listed in items 5 (a)-(f).
The department retains the right to audit any exemption or extension granted at any time.
Texas Department of Insurance |
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