Matt Rosendale
Commissioner of Securities & Insurance
Montana State Auditor
840 Helena Ave
Helena, MT 59601
Phone: 406.444.2040
800.332.6148
Fax: 406.444.3497
www.csimt.gov
INDIVIDUAL COURSE SUBMISSION PACKET
FOR A
MONTANA INSURANCE PRODUCER, ADJUSTER or CONSULTANT
Producer/Adjuster/Consultant Name
Insurance License Number(s)
Mailing Address
City State Zip Code
Phone Number
E-mail Address
Course Name
Course Provider
Checklist:
Submitted less than 45 days after course end
Copy of course completion certificate from course provider attached
All questions answered in attached packet
Copy of course agenda, syllabus or outline attached
Photocopy of this completed packet kept for my records
Application signed.
Course Number
Reception Number
For Departmental Use Only
Form CE-3, 10/2011
2
1. The course was completed (month) (day) , (year) .
(please, use the date from the completion certificate)
2. I am a Montana Insurance Producer Yes No
3. I am a Montana Insurance Consultant Yes No
4. I am a Montana Insurance Adjuster Yes No
5. This was a college or university course Yes No
If, yes, name of college or university
6. The course was taught in this method:
Classroom (an instructor or instructors taught the course materials).
Correspondence (I studied a book and completed and passed a test).
Videotape (I watched a videotape and completed and passed a test).
Audiotape (I listened to an audiotape and completed and passed
a test).
Teleconference (I went to a scheduled teleconference site that was
monitored by the course provider).
Other (I completed a computer-based course and completed and
passed a test) or (write a description of the method)
7. The name(s) of the instructor(s) is/are:
.
Form CE-3, 10/2011
3
Attach additional pages, as needed. Please type or print your responses.
8. D
escribe what you learned during each course session or segment.
Form CE-3, 10/2011
4
9. The goals and objectives of the course were:
.
10
. The major course topic was:
.
11. The course was hours long.
12. To enroll in this course, I contacted
at (phone number)
(or address)
I request the attached materials be reviewed for certification and approval by the
Montana Insurance Continuing Education Program. I certify the information
submitted regarding this course is true and correct. I understand that additional
material may be requested by the Montana Insurance Continuing Education
Program, as part of the course review and certification process. I understand any
approval or credit hours assigned this course as a result of this submission can only
be used by me to meet my biennial insurance continuing education requirement.
Name (please print) Signature Date
R
eproduction of this application packet is encouraged.