Prelicensing/Continuing Education Program Instructor/Subject Matter Expert Qualification (LIC 446-4)

State of California Department of Insurance

Instructor/Subject Matter Expert Qualification Form

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 446-4 (Rev. 1/2023)

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.
  • Provider Director must verify the information provided by the instructor/subject matter expert.
I am preparing this form as:

Provider Information

Instructor/Subject Matter Expert Information

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.

Courses to be Taught

List the course titles and course numbers to be taught:

Insurance Licenses

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

License Type
License Type
License Type
License Type
License Type
License Type
License Type
License Type
License Type
License Type
License Type
License Type
License Type
License Type
License Type

Degree

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

Insurance Designations

Please indicate if you hold a recognized professional insurance designation:

Credentials

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

Providers

Have you ever been an instructor/subject matter expert for another prelicensing or continuing education provider?

Background Questions

1. Have you been the subject of any administrative agency disciplinary action? For the purpose of this question,administrative agency disciplinary action includes but is not limited to: having any professional, vocational or businesslicense denied, suspended, placed on probation, restricted or revoked, or any fine imposed; withdrawing any application orsurrendering any license to avoid disciplinary action; being issued a cease and desist order or its equivalent; being thesubject of a conservation, liquidation, rehabilitation or receivership order.
2. Have you ever been convicted of a crime? For the purpose of this question, "crime" includes a felony ormisdemeanor and military offenses. "Convicted" includes, but is not limited to, having been found guilty by verdictof a judge or jury, having entered a plea of guilty or nolo contendere, having had any charge dismissed, expungedor plea withdrawn pursuant to Penal Code Section 1203.4, or having been given probation, a suspended sentenceor a fine. You may exclude traffic citations and juvenile offenses.

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.

Instructor/Subject Matter Expert Certification

Provider Director Verification

  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.