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INSTRUCTIONS:
This form must be completed by each proposed instructor/subject matter expert, lecturer, moderator, or person conducting a classroom course, seminar, workshop, conference, or person identified by the provider to respond to non-contact course student questions.

List the course titles and course numbers to be taught:

If you hold or have ever held an insurance license, complete the following:

If you have a college degree in the subject matter being taught, complete the following:

If you hold a recognized professional credential in the subject matter being taught, complete the following:

IMPORTANT NOTE: If the instructor/subject matter expert answer is "YES" to either of the above two questions, theinstructor/subject matter expert is to attach a detailed statement, signed by you, listing the events which led to the charges (dates and places). If the matter was heard in court, attach copies CERTIFIED BY THE COURT of the Criminal Complaint and the Sentencing Minute Order showing the final plea, judgment and sentence. If any disciplinary action was taken by an administrative agency, attach a certified copy of the action.

1. Copy of degree, license, or certificate in the subject matter being taught;
2. Curriculum vitae, resume or transcripts stating instructor/subject matter expert’s experience, qualificationsand education;
3. Documents or letters from a third party including but not limited to a supervisor, professor, attorney,legislator, or certified public accountant that demonstrates the instructor/subject matter expert meets theminimum requirements; or
4. Documentation that the instructor/subject matter expert has successfully completed a course that meets therequirements of Section 1749.4 of the California Insurance Code.