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Maryland Insurance Administration 200 St. Paul Place, Suite 2700, Baltimore MD 21202 PRE-LICENSING INSURANCE EDUCATION WAIVER / AFFIDAVIT OF EMPLOYER Submission may be made via mail to the above address, fax to (410)468-2399 or email to [email protected]. The completed waiver application and supporting documents must be sent to and approved by the Maryland Insurance Administration before taking the examination. All applicants must complete this section fully and legibly: Name of Applicant:___________________________________________________ Date of Birth:________________ Social Security #:__________________________Email Address:__________________________________________ Address:_______________________________________________________________________________________ City: ________________________________State:__________Zip:____________Phone:______________________ TYPE OF PRE-LICENSING EDUCATION WAIVER REQUESTED (check all applicable) LIFE HEALTH PROPERTY CASUALTY PERSONAL LINES TITLE Reason for education waiver request (check one that applies): Maintain insurance designation in good standing. Provide a current letter of good standing issued by the conferring organization for the appropriate line of authority/ies. (AAI, ARM, CIC, CPCU, CLU, CEBS, ChFC, CFP, FLMI, LUTCF, REBC, RHU, HIA, Fellow Casualty Actuarial Society) Equivalent college courses taken. Attach transcript of insurance course(s) showing college credits and official course description(s) from the college catalog. Recent work experience in the lines of authority applicant will be testing (Reference: 10-104 and 10-105). The work experience must be with one of the following types of employer: Maryland Insurance Administration, Insurance Company, or Insurance Producer (or Firm). The period of work must be at least one year within the past 3 calendar years. In order to complete the one year, more than one employer may need to complete the affidavit. Along with this form, the employer must submit both: The notarized Affidavit of Employer below attesting to applicant’s employment and a Detailed list of applicant’s duties and responsibilities that would result in becoming reasonably familiar with basic policy forms, fundamental procedures and practices for the line(s) of insurance that applicant will be testing. For Title, employee must have experience and responsibilities in three of the following categories: Title Search & Abstract Review Preparation & Review of Commitments / Policies Examination of Title Settlement Accounting Procedures AFFIDAVIT OF EMPLOYER Under the provisions of the Maryland Insurance laws, and in support of an application for an insurance license examination I hereby declare the Applicant has been regularly employed by: Name of Employer:___________________________________ Signature of Employer Representative:____________________ Title:_____________ Address:_________________________________________________________________________________________________________________ Type of Employer (check one): Insurance Company ___ Insurance Producer or Firm ___ For period(s) from: _______________to ________________ Work Hours: Full Time (40+ Hours) ____ Part-Time (Less than 40 hours) ____ Please indicate hours per week:_______________________________ _______________________________________________________ _____________________ _______________________ Name of Producer or Insurer Telephone Number Date State of ________________________________________City/County of ____________________________________________________________ On this ________ day of _________________, personally appear before me the said named ____________________________________________ Known to me to be the person described in and who executed the foregoing instrument and he/she acknowledge the same and, being duly sworn by me , made oath the statements in the application are true. ________________________________________________ My commission expires: _______________________________ Notary Public
Transcript of d Z } u o Á ] À o ] ] } v v µ } ] v P } µ u v u µ v } v } À Ç Z D Ç o v / v µ ... · 2020....
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Maryland Insurance Administration 200 St. Paul Place, Suite 2700, Baltimore MD 21202
PRE-LICENSING INSURANCE EDUCATION WAIVER / AFFIDAVIT OF EMPLOYER Submission may be made via mail to the above address, fax to (410)468-2399 or email to [email protected].
The completed waiver application and supporting documents must be sent to and approved by the Maryland Insurance Administration before taking the examination.
All applicants must complete this section fully and legibly:
Name of Applicant:___________________________________________________ Date of Birth:________________ Social Security #:__________________________Email Address:__________________________________________ Address:_______________________________________________________________________________________ City: ________________________________State:__________Zip:____________Phone:______________________
TYPE OF PRE-LICENSING EDUCATION WAIVER REQUESTED (check all applicable)
LIFE HEALTH PROPERTY CASUALTY PERSONAL LINES TITLE Reason for education waiver request (check one that applies): Maintain insurance designation in good standing. Provide a current letter of good standing issued by the conferring organization for the appropriate line of authority/ies. (AAI, ARM, CIC, CPCU, CLU, CEBS, ChFC, CFP, FLMI, LUTCF, REBC, RHU, HIA, Fellow Casualty Actuarial Society) Equivalent college courses taken. Attach transcript of insurance course(s) showing college credits and official course description(s) from the college catalog. Recent work experience in the lines of authority applicant will be testing (Reference: 10-104 and 10-105). The work experience must be with one of the following types of employer: Maryland Insurance Administration, Insurance Company, or Insurance Producer (or Firm). The period of work must be at least one year within the past 3 calendar years. In order to complete the one year, more than one employer may need to complete the affidavit. Along with this form, the employer must submit both: The notarized Affidavit of Employer below attesting to applicant’s employment and a Detailed list of applicant’s duties and responsibilities that would result in becoming reasonably familiar with basic policy forms, fundamental procedures and practices for the line(s) of insurance that applicant will be testing. For Title, employee must have experience and responsibilities in three of the following categories: Title Search & Abstract Review Preparation & Review of Commitments / Policies Examination of Title Settlement Accounting Procedures
AFFIDAVIT OF EMPLOYER Under the provisions of the Maryland Insurance laws, and in support of an application for an insurance license examination I hereby declare the Applicant has been regularly employed by: Name of Employer:___________________________________ Signature of Employer Representative:____________________ Title:_____________ Address:_________________________________________________________________________________________________________________ Type of Employer (check one): Insurance Company ___ Insurance Producer or Firm ___ For period(s) from: _______________to ________________ Work Hours: Full Time (40+ Hours) ____ Part-Time (Less than 40 hours) ____ Please indicate hours per week:_______________________________ _______________________________________________________ _____________________ _______________________ Name of Producer or Insurer Telephone Number Date State of ________________________________________City/County of ____________________________________________________________ On this ________ day of _________________, personally appear before me the said named ____________________________________________ Known to me to be the person described in and who executed the foregoing instrument and he/she acknowledge the same and, being duly sworn by me , made oath the statements in the application are true. ________________________________________________ My commission expires: _______________________________ Notary Public
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