Prelicensing/Continuing Education Program List Instructor(s)/Subject Matter Expert(s) (LIC 446-4A)

State of California Department of Insurance

List of Instructor(s)/Subject Matter Expert(s)

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 446-4A (Rev. 1/2023)

The provider shall submit to the Commissioner a list of all instructors and/subject matter experts that it uses for all of its approved courses. The list will be provided to the Commissioner at the time the provider submits the initial provider certification application, at the time of renewing the provider certification, and at any other time that a new instructor/subject matter expert is authorized to teach or respond to students’ questions for active prelicensing or continuing education 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

Subject Matter Expert - I need to send the form to the Provider Director

I am the Provider Director

Provider Director Name

Provider Director Email

List of Instructor(s)/Subject Matter Expert(s)

Last Name

First Name

Middle Name

License #/NPN

Social Security

Instructor or SME Value is not selected

Last Name

First Name

Middle Name

License #/NPN

Social Security

Instructor or SME Value is not selected

Last Name

First Name

Middle Name

License #/NPN

Social Security

Instructor or SME Value is not selected

Last Name

First Name

Middle Name

License #/NPN

Social Security

Instructor or SME Value is not selected

Last Name

First Name

Middle Name

License #/NPN

Social Security

Instructor or SME Value is not selected

Add Additional Instructors/Subject Matter Experts

Last Name

First Name

Middle Name

License #/NPN

Social Security

Instructor or SME Value is not selected

Last Name

First Name

Middle Name

License #/NPN

Social Security

Instructor or SME Value is not selected

Last Name

First Name

Middle Name

License #/NPN

Social Security

Instructor or SME Value is not selected

Last Name

First Name

Middle Name

License #/NPN

Social Security

Instructor or SME Value is not selected

Last Name

First Name

Middle Name

License #/NPN

Social Security

Instructor or SME Value is not selected

Add Additional Instructors/Subject Matter Experts

Last Name

First Name

Middle Name

License #/NPN

Social Security

Instructor or SME Value is not selected

Last Name

First Name

Middle Name

License #/NPN

Social Security

Instructor or SME Value is not selected

Last Name

First Name

Middle Name

License #/NPN

Social Security

Instructor or SME Value is not selected

Last Name

First Name

Middle Name

License #/NPN

Social Security

Instructor or SME Value is not selected

Last Name

First Name

Middle Name

License #/NPN

Social Security

Instructor or SME Value is not selected

Add Additional Instructors/Subject Matter Experts

Last Name

First Name

Middle Name

License #/NPN

Social Security

Instructor or SME Value is not selected

Last Name

First Name

Middle Name

License #/NPN

Social Security

Instructor or SME Value is not selected

Last Name

First Name

Middle Name

License #/NPN

Social Security

Instructor or SME Value is not selected

Last Name

First Name

Middle Name

License #/NPN

Social Security

Instructor or SME Value is not selected

Last Name

First Name

Middle Name

License #/NPN

Social Security

Instructor or SME Value is not selected

Upload Supporting Documentation If needed

Provider Director

Comments to the Subject Matter Expert

Signature of Provider Director

Date:

Printed Name of Provider Director:

Contact Email

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Prelicensing/Continuing Education Program List Instructor(s)/Subject Matter Expert(s) (LIC 446-4A)

List of Instructor(s)/Subject Matter Expert(s)

Provider Director