Class Presentation Schedule (LIC 446-12)

State of California Department of Insurance

Class Presentation Schedule

Department of Insurance
Curriculum and Officer Review Bureau - Education Unit
300 Capitol Mall
Sacramento, CA 95814-4309
Information: (916) 492-3064
www.insurance.ca.gov

LIC 446-12 (Rev. 1/2023)

Please note: Class Presentation Schedule is only required for Contact courses.

Provider Number

Provider Name

Response from Provider Number Check Provider Number through SIRCON - Pull name from SIRCON.

I am preparing this form as:

Administrative Assistant - I need to send the form to the Provider Director/SME

I am the Provider Director

Provider Director Name

Provider Director Email

Instructions:

USE A SEPARATE SUBMISSION FOR EACH CLASS PRESENTATION.
To inform the Department of a new class, mark NEW box and provide all pertinent information below.
To notify the Department of a change to a class schedule previously submitted, mark CHANGE, give the original date, time, location and provide new information below.
To cancel a class previously submitted, mark CANCEL and complete information below.
Completed form must be received by the Department at least 14 days prior to the original class presentation. Subsequent presentations must be received at least 10 days prior to class presentation. No faxes will be accepted.
Late schedules may not be accepted and attendees may not receive continuing education credit.
The information provided below must match the information on the certificate of completion and the provider roster.

Check One

New

Cancel

Change

Original Date/Time

In-House Offering (If marked this will not show on department's website Provider and Course Search.)

Original Location

Course ID#

Credit Hours

Instructor Name

Course Name

Start Date

End Date

Start Time

End Time

Today's Date

Start Date Compared to Today's Date

10 days

Explanation for Start Date not 10 Days in Advance

Upload Documentation

Location of Presentation

Street Address

Room/Suite

City

State Value is not selected

Zip

Daily Presentation Schedule

If course spans more than one day, each day must be listed in Daily Presentation Schedule chart below.

Day

Date (Month/Day/Year)

Begin Time

End Time

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Provider Director Certification

I certify that the class information provided here is true and correct to the best of my knowledge. Any changes will be provided to the Department promptly. *

Signature of Provider Director

Date

Printed Name of Provider Director

Phone Number

Start Date

End Date

Convert 1

Convert 2

Convert 3

Convert 4

Convert 5

Convert 6

Convert 7

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Class Presentation Schedule (LIC 446-12)

Location of Presentation

Daily Presentation Schedule

Provider Director Certification