Form Fin518 - Course Assignment Form - Texas Department Of Insurance
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2FIN518 | 0115
COURSE ASSIGNMENT FORM
FEE: $50
Must be typewritten or legibly printed in ink. May also be completed vià internet.
Please read the Instructions before continuing.
Part A: General Information
1) Assignee’s current provider registration number: __________________________________
Assignee’s registered name: ___________________________________________________
2) Indicate a yes or no response to the following questions by checking the applicable box:
Yes*
No
a.
Will assignee change more than 25% of the certified course content?
b.
Will assignee change the number of certified course credit hours?
c.
Will assignee change the type of certified course credit hours?
d.
Will assignee write and use examinations different from those developed by assignor?
*Refer to Part A: (2) of the instructions for any yes answers for (a)-(d)
e.
Will course be open to the public?
3) Assignor’s current provider registration number:
4) Assignor’s registered name:
The actual calendar date the assignment is proposed to be effective:
______ / ______ / ______
5) The actual calendar date the assignment terminates: ______ / ______ / ______**
**May not be more than two years from (4). Assignment terminates automatically and must be redone if
assignor’s course is not recertified by its expiration date. Please see instructions for more.
6) The course being assigned has been certified by the department as:
a. Name of the course as certified: ______________________________________________________
b. The original course certification number: _______________________________________________
c. The original course expiration date: ______ / ______ / ______
Part B: Certification
We certify that we will conform to the provisions of 28 TAC §§19.1008(f) and 19.1012(b) (3).
_____________________________________________
__________________________
Assignor Authorized Provider Representative Signature
Date Signed
_____________________________________________
__________________________
Assignee Authorized Provider Representative Signature
Date Signed
Texas Department of Insurance |
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