Form KYP-01 "Provider Approval Application - Continuing Education/Pre-licensing Program" - Kentucky

What Is Form KYP-01?

This is a legal form that was released by the Kentucky Department of Insurance - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2021;
  • The latest edition provided by the Kentucky Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form KYP-01 by clicking the link below or browse more documents and templates provided by the Kentucky Department of Insurance.

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Download Form KYP-01 "Provider Approval Application - Continuing Education/Pre-licensing Program" - Kentucky

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KYP-01 (9/2021)
Kentucky Department of Insurance
Continuing Education/Pre-Licensing Program
Provider Approval Application
 Continuing Education
 Pre-Licensing
P
P
T
. P
N
.
LEASE
RINT OR
YPE
HOTOCOPY AS
EEDED
Provider Name
FEIN
Prometric Use Only
Names and Titles of Owners or Officers (list below)
Name
Title
Address
City
State
Zip Code
Contact Person
Title
Voice Phone #:
Ext.
Fax #:
E-mail Address
URL:
How long have you been in business?
(Web site address)
 Insurance Company
 Professional Organization
Type of
 Independent Provider
 College/University
Organization:
 Government Entity
(check one)
New Providers for the Commonwealth of Kentucky must include approval or exemption document from the Kentucky
Board for Proprietary Education. For additional information on this requirement, please visit that Web site at:
http://bpe.ky.gov
or phone directly (502) 564-3296.
 Yes
 No
Have you operated under any other name?
If yes,
Name
Address
I certify that I have read the requirements for Kentucky Pre-License Training or Continuing Education Providers
and agree to abide by them and will abide by Kentucky insurance laws and regulations, the Americans with
Disabilities Act, and all applicable state and federal equal employment opportunity and safety requirements.
Additionally, I will require any instructors I utilize to teach courses to certify that they satisfy the requirements to
be an instructor and to abide by those requirements applicable to instructors. I am aware that any failure to abide
by the requirements may result in the termination of this Provider’s authorization to offer courses and that all
course approvals will be simultaneously withdrawn.
Applicant’s Signature
Date
__________________________
Title
Print or Type Name
Return this completed form to
Prometric Operations Center, 7941 Corporate Drive, Nottingham, MD
21236. Send a copy of this form to DOI.LicensingMail@ky.gov.
KYP-01 (9/2021)
Kentucky Department of Insurance
Continuing Education/Pre-Licensing Program
Provider Approval Application
 Continuing Education
 Pre-Licensing
P
P
T
. P
N
.
LEASE
RINT OR
YPE
HOTOCOPY AS
EEDED
Provider Name
FEIN
Prometric Use Only
Names and Titles of Owners or Officers (list below)
Name
Title
Address
City
State
Zip Code
Contact Person
Title
Voice Phone #:
Ext.
Fax #:
E-mail Address
URL:
How long have you been in business?
(Web site address)
 Insurance Company
 Professional Organization
Type of
 Independent Provider
 College/University
Organization:
 Government Entity
(check one)
New Providers for the Commonwealth of Kentucky must include approval or exemption document from the Kentucky
Board for Proprietary Education. For additional information on this requirement, please visit that Web site at:
http://bpe.ky.gov
or phone directly (502) 564-3296.
 Yes
 No
Have you operated under any other name?
If yes,
Name
Address
I certify that I have read the requirements for Kentucky Pre-License Training or Continuing Education Providers
and agree to abide by them and will abide by Kentucky insurance laws and regulations, the Americans with
Disabilities Act, and all applicable state and federal equal employment opportunity and safety requirements.
Additionally, I will require any instructors I utilize to teach courses to certify that they satisfy the requirements to
be an instructor and to abide by those requirements applicable to instructors. I am aware that any failure to abide
by the requirements may result in the termination of this Provider’s authorization to offer courses and that all
course approvals will be simultaneously withdrawn.
Applicant’s Signature
Date
__________________________
Title
Print or Type Name
Return this completed form to
Prometric Operations Center, 7941 Corporate Drive, Nottingham, MD
21236. Send a copy of this form to DOI.LicensingMail@ky.gov.