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Important: This form must be submitted to the Commissioner within 10 days following the completion of the prelicensing course and 30 days following the completion of the continuing education course.

Late rosters may not be accepted.

The Commissioner requests disclosure of a student's last four digits of his or her social security number and the student’s birth date shown as month, day, and year (mm/dd/yyyy) pursuant to Insurance Code Sections 1749, 1749.2, 1749.3, 1749.4, 1749.5, and 1749.7, and California Code of Regulations, Title 10, Chapter 5, Sections 2188.4(b) and 2188.5(b)(1). This information will enable the Commissioner to properly identify and assign credit to students who have completed a prelicensing course. For continuing education courses, the student’s insurance license number is required. While a student's disclosure of his or her full birth date and the last four digits of his or her social security number are not mandatory, any failure to provide this information may delay or otherwise impede the Commissioner in assigning credit for the completion of such courses to the appropriate students.

Prelicensing roster needs First & Last name, last four of the ssn and DOB. CE rosters can be processed with last name and license number, or just the license number.